Provider Demographics
NPI:1962539106
Name:REISCHACH, LISA LEE (PT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LEE
Last Name:REISCHACH
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 1:48584 DEBRA CIR
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-9436
Mailing Address - Country:US
Mailing Address - Phone:907-776-5784
Mailing Address - Fax:907-776-5786
Practice Address - Street 1:150 N WILLOW ST STE 15
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-9109
Practice Address - Country:US
Practice Address - Phone:907-283-2765
Practice Address - Fax:907-283-2765
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT5625Medicaid