Provider Demographics
NPI:1205059870
Name:DUCKWORTH, LISA S (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 JOHN E SULLIVAN RD
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-5608
Mailing Address - Country:US
Mailing Address - Phone:478-956-4205
Mailing Address - Fax:478-956-4205
Practice Address - Street 1:3051 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8536
Practice Address - Country:US
Practice Address - Phone:478-953-7556
Practice Address - Fax:478-953-4677
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1494225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant