Provider Demographics
NPI:1215714811
Name:HORTON, LISA LORIENE (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LORIENE
Last Name:HORTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-9009
Mailing Address - Country:US
Mailing Address - Phone:509-671-3780
Mailing Address - Fax:
Practice Address - Street 1:1201 W 5TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156-9183
Practice Address - Country:US
Practice Address - Phone:509-447-0656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1-61159606225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant