Provider Demographics
NPI:1184059826
Name:SEDGLEY, LISA L (PTA-L)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:L
Last Name:SEDGLEY
Suffix:
Gender:F
Credentials:PTA-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17615 W MOORE
Mailing Address - Street 2:PO BOX 518
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-9408
Mailing Address - Country:US
Mailing Address - Phone:231-834-0208
Mailing Address - Fax:616-965-2475
Practice Address - Street 1:25 CONRAN DR
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1366
Practice Address - Country:US
Practice Address - Phone:616-997-6172
Practice Address - Fax:616-965-2475
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002946225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant