Provider Demographics
NPI:1386123008
Name:PETROSS, LISA (PT, DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PETROSS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:WENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:920 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-3196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-3196
Practice Address - Country:US
Practice Address - Phone:940-553-2857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1280647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist