Provider Demographics
NPI:1629804539
Name:TOLLE, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TOLLE
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 1:7000 ALSTON CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-7757
Mailing Address - Country:US
Mailing Address - Phone:502-762-7119
Mailing Address - Fax:
Practice Address - Street 1:1188 S STATE ROUTE 157
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3614
Practice Address - Country:US
Practice Address - Phone:618-692-5930
Practice Address - Fax:618-692-5931
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist