Provider Demographics
NPI:1265952592
Name:PETERSON, LISA (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:T
Other - Last Name:WEIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:893 94TH ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-4911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:893 94TH ST
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-4911
Practice Address - Country:US
Practice Address - Phone:262-948-0525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant