Basic Information
| Provider Information | |||||||||
| NPI: | 1003007451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 556 AUBUCHON RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633794338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363384095 | ||||||||
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| Practice Location | |||||||||
| Address1: | 556 AUBUCHON RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633794338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363384095 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2007 | ||||||||
| LastUpdateDate: | 08/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2000154583 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.