Provider Demographics
NPI:1780748004
Name:PHELPS, LISA MAUREEN (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MAUREEN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MAUREEN
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:511 JERMOR LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6151
Mailing Address - Country:US
Mailing Address - Phone:410-876-8076
Mailing Address - Fax:
Practice Address - Street 1:431 E RIDGEVILLE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5217
Practice Address - Country:US
Practice Address - Phone:301-829-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160584OtherUNITED HEALTHCARE
2160584OtherACN
543042-04OtherBCBS OF MARYLAND
7914198OtherAETNA
T208OtherBLUECHOICE/GHMSI
7914198OtherAETNA
T208OtherBLUECHOICE/GHMSI