Provider Demographics
NPI:1316497092
Name:ICKE, LISA ANN
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:ICKE
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 1:16911 REDLAND DOWNS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-2834
Mailing Address - Country:US
Mailing Address - Phone:210-445-0241
Mailing Address - Fax:
Practice Address - Street 1:16911 REDLAND DOWNS
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-2834
Practice Address - Country:US
Practice Address - Phone:210-445-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1098960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist