Provider Demographics
NPI:1982886198
Name:MOULSE, LISA M (DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MOULSE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-5204
Mailing Address - Country:US
Mailing Address - Phone:540-982-2208
Mailing Address - Fax:540-982-7637
Practice Address - Street 1:1421 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5204
Practice Address - Country:US
Practice Address - Phone:540-982-2208
Practice Address - Fax:540-982-7637
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist