Provider Demographics
NPI:1972991487
Name:DEPAUL, LISA (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DEPAUL
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 1:5035 RELA WAY W
Mailing Address - Street 2:
Mailing Address - City:QUARTZ HILL
Mailing Address - State:CA
Mailing Address - Zip Code:93536-2511
Mailing Address - Country:US
Mailing Address - Phone:734-276-7932
Mailing Address - Fax:
Practice Address - Street 1:1642 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2814
Practice Address - Country:US
Practice Address - Phone:661-942-8463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8875225200000X
OH03425225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant