Provider Demographics
NPI:1386054617
Name:HEPNER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HEPNER
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 1:2609 CHARLEVOIX AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8524
Mailing Address - Country:US
Mailing Address - Phone:231-439-3750
Mailing Address - Fax:
Practice Address - Street 1:2609 CHARLEVOIX AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8524
Practice Address - Country:US
Practice Address - Phone:231-439-3750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004155225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant