Provider Demographics
NPI:1285928028
Name:RAU, LISA C (PT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:C
Last Name:RAU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:C
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:193 E. JEFFERSON ST.
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734
Mailing Address - Country:US
Mailing Address - Phone:989-652-4040
Mailing Address - Fax:989-652-4703
Practice Address - Street 1:193 E. JEFFERSON ST.
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734
Practice Address - Country:US
Practice Address - Phone:989-652-4040
Practice Address - Fax:989-652-4703
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236669Medicare PIN