Provider Demographics
NPI:1528310547
Name:HARDIMON, LISA MARIE (MPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HARDIMON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:VINCENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2621 MANHATTAN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-1604
Mailing Address - Country:US
Mailing Address - Phone:310-374-0477
Mailing Address - Fax:310-374-1605
Practice Address - Street 1:2621 MANHATTAN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-1604
Practice Address - Country:US
Practice Address - Phone:310-374-0477
Practice Address - Fax:310-374-1605
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT199022251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT19902OtherPT LICENSE