Provider Demographics
NPI:1053536656
Name:LISK, ALDA L
Entity type:Individual
Prefix:
First Name:ALDA
Middle Name:L
Last Name:LISK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALDA
Other - Middle Name:L
Other - Last Name:LIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5385 ORCHID LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3789
Mailing Address - Country:US
Mailing Address - Phone:612-860-9654
Mailing Address - Fax:
Practice Address - Street 1:5385 ORCHID LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3789
Practice Address - Country:US
Practice Address - Phone:612-860-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016375225100000X
MN8963225100000X
OH011718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist