Provider Demographics
NPI:1336366947
Name:ULRICH, LISA BRADFORD (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BRADFORD
Last Name:ULRICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:BRADFORD
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6962 W 85TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-2603
Mailing Address - Country:US
Mailing Address - Phone:310-890-7584
Mailing Address - Fax:310-642-1195
Practice Address - Street 1:150 SIERRA ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4117
Practice Address - Country:US
Practice Address - Phone:310-890-7584
Practice Address - Fax:310-642-1195
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist