Provider Demographics
NPI:1295743102
Name:WELTON, LISA JEAN (PT)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:JEAN
Last Name:WELTON
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 1:10131 MEREDITH DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-4926
Mailing Address - Country:US
Mailing Address - Phone:714-330-7485
Mailing Address - Fax:
Practice Address - Street 1:2600 EAST PACIFIC COAST HIGHWAY
Practice Address - Street 2:STE. 240
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625
Practice Address - Country:US
Practice Address - Phone:949-640-2121
Practice Address - Fax:949-640-2631
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT12602AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER