Provider Demographics
NPI:1124629662
Name:LY, LISA I (DC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:I
Last Name:LY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2133 S GREAT SOUTHWEST PKWY STE 505
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3546
Mailing Address - Country:US
Mailing Address - Phone:726-472-4009
Mailing Address - Fax:972-623-3400
Practice Address - Street 1:2133 S GREAT SOUTHWEST PKWY STE 505
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3546
Practice Address - Country:US
Practice Address - Phone:972-647-2400
Practice Address - Fax:972-623-3400
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14518111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14518OtherCHIROPRACTIC