Provider Demographics
NPI:1912102443
Name:MCGOWAN, LISA ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 OTROBANDO AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2116
Mailing Address - Country:US
Mailing Address - Phone:860-889-1948
Mailing Address - Fax:
Practice Address - Street 1:150 OTROBANDO AVENUE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360
Practice Address - Country:US
Practice Address - Phone:860-889-1948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0014101OtherORTHONET HEALTHNET
CT14101OtherORTHONET CIGNA
CT004189024Medicaid
CTA2752221OtherOXFORD
CT061503332005OtherTRICARE