Provider Demographics
NPI:1528077559
Name:GOHDES, LISA DAWN (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DAWN
Last Name:GOHDES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 W. 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRP
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3418
Mailing Address - Country:US
Mailing Address - Phone:310-548-9748
Mailing Address - Fax:
Practice Address - Street 1:3250 LOMITA BOULEVARD
Practice Address - Street 2:SUITE 306
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5006
Practice Address - Country:US
Practice Address - Phone:310-539-8800
Practice Address - Fax:310-698-5414
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 1965225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant