Basic Information
| Provider Information | |||||||||
| NPI: | 1649715871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY STE 100 | ||||||||
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| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065202 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 W NORTH 12TH ST | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625659554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177742111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2016 | ||||||||
| LastUpdateDate: | 12/26/2016 | ||||||||
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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 | 225200000X | 160.007630 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.