Provider Demographics
NPI:1184942542
Name:PHILLIPS, LISA COLE (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:COLE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 BACK SQUARE DR STE A2
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-7411
Mailing Address - Country:US
Mailing Address - Phone:270-316-1812
Mailing Address - Fax:270-240-4500
Practice Address - Street 1:5000 BACK SQUARE DR STE A2
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-7411
Practice Address - Country:US
Practice Address - Phone:270-316-1812
Practice Address - Fax:270-240-4500
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0101225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist