Provider Demographics
NPI:1295890226
Name:COULTER, LISA M (REEGT,RPSGT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:COULTER
Suffix:
Gender:F
Credentials:REEGT,RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8694
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71910-8694
Mailing Address - Country:US
Mailing Address - Phone:501-860-6130
Mailing Address - Fax:501-860-6054
Practice Address - Street 1:2101 CONGO
Practice Address - Street 2:SUITE 900
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2750
Practice Address - Country:US
Practice Address - Phone:501-315-8818
Practice Address - Fax:501-315-8828
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR247200000X, 2472E0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C246Medicare ID - Type UnspecifiedMEDICARE