Provider Demographics
NPI:1881991735
Name:ERTLE, LISA (DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ERTLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:210 CLEAVER FARMS RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1670
Mailing Address - Country:US
Mailing Address - Phone:302-449-2048
Mailing Address - Fax:
Practice Address - Street 1:210 CLEAVER FARMS RD STE 1
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1670
Practice Address - Country:US
Practice Address - Phone:302-449-2048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002669225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEP00976381OtherMEDICARE RAILROAD
DE802937Y0XMedicare PIN