Provider Demographics
NPI:1720483134
Name:DEJANOVICH, LISA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:DEJANOVICH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13157 S CARONDOLET AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60633-1703
Mailing Address - Country:US
Mailing Address - Phone:773-646-4126
Mailing Address - Fax:
Practice Address - Street 1:13157 S CARONDOLET AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60633-1703
Practice Address - Country:US
Practice Address - Phone:773-646-4126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.003705225200000X
IN06004851A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant