Provider Demographics
NPI:1386116085
Name:RIVERASHUMWAY, LISA RAE (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RAE
Last Name:RIVERASHUMWAY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6607
Mailing Address - Country:US
Mailing Address - Phone:909-798-2129
Mailing Address - Fax:
Practice Address - Street 1:3401 LEMON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-2861
Practice Address - Country:US
Practice Address - Phone:951-686-8202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist