Provider Demographics
NPI:1093922304
Name:ANDERSEN, LISA KATHLEEN (PT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:KATHLEEN
Last Name:ANDERSEN
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 1:380 SOUTH POTEET AVE.
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067
Mailing Address - Country:US
Mailing Address - Phone:847-858-2771
Mailing Address - Fax:
Practice Address - Street 1:525 E CONGRESS PKWY STE 210
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6258
Practice Address - Country:US
Practice Address - Phone:847-842-4846
Practice Address - Fax:847-842-4465
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006773I225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist