Provider Demographics
NPI:1881934446
Name:HEALY, LISA L (PTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:L
Last Name:HEALY
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 1:611 S MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-1213
Mailing Address - Country:US
Mailing Address - Phone:618-643-2361
Mailing Address - Fax:618-643-3657
Practice Address - Street 1:611 S MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1213
Practice Address - Country:US
Practice Address - Phone:618-643-2361
Practice Address - Fax:618-643-3657
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004769225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant