Provider Demographics
NPI:1194423905
Name:TESCH, LISA G
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:TESCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9292
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40209-0292
Mailing Address - Country:US
Mailing Address - Phone:502-579-0153
Mailing Address - Fax:
Practice Address - Street 1:237 GLENDORA AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-2529
Practice Address - Country:US
Practice Address - Phone:502-579-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251E00000X, 253Z00000X, 347E00000X, 376J00000X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No347E00000XTransportation ServicesTransportation Broker
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY120452493Medicaid