Provider Demographics
NPI:1205951340
Name:SMITH, LISA MICHELLE (PT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MERCY CIRCLE BOX 555191
Mailing Address - Street 2:NAVAL HOSPITAL CAMP PENDLETON
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:760-725-7159
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIRCLE
Practice Address - Street 2:BOX 555191 NAVAL HOSPITAL CAMP PENDLETON
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-719-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL38474225100000X
CA15080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT15080AMedicare PIN