Provider Demographics
NPI:1255374674
Name:BRISCO, LOIS (PT)
Entity type:Individual
Prefix:MRS
First Name:LOIS
Middle Name:
Last Name:BRISCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 UTAH AVE S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3671
Mailing Address - Country:US
Mailing Address - Phone:952-933-1121
Mailing Address - Fax:952-945-9536
Practice Address - Street 1:3015 UTAH AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3671
Practice Address - Country:US
Practice Address - Phone:952-933-1121
Practice Address - Fax:952-945-9536
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN843OtherMHP
MNHP46102OtherHP