Provider Demographics
NPI:1306980834
Name:FLORES, LISA MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:FLORES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:BRACKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12105 AMBASSADOR DRIVE
Mailing Address - Street 2:LIBERTY HEIGHTS (PARAGON REHAB)
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921
Mailing Address - Country:US
Mailing Address - Phone:719-439-9667
Mailing Address - Fax:
Practice Address - Street 1:12105 AMBASSADOR DRIVE
Practice Address - Street 2:LIBERTY HEIGHTS (PARAGON REHAB)
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921
Practice Address - Country:US
Practice Address - Phone:719-493-9667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60415386225200000X
TX2059028225200000X
COPTA.0012393225200000X
IDPTA-3689225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant