Provider Demographics
NPI:1245445329
Name:BRACK WARREN, LISA (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRACK WARREN
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 1:7208 MACKENZIE CT NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-8467
Mailing Address - Country:US
Mailing Address - Phone:505-867-5825
Mailing Address - Fax:
Practice Address - Street 1:10101 W PALMERAS DR
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85373-2046
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:877-407-4329
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM22682251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics