Provider Demographics
NPI:1679694087
Name:MCCARRELL, LISA A (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MCCARRELL
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 1:206 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2418
Mailing Address - Country:US
Mailing Address - Phone:517-783-6670
Mailing Address - Fax:517-783-5310
Practice Address - Street 1:865 OLDS ST STE D4
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:MI
Practice Address - Zip Code:49250-9478
Practice Address - Country:US
Practice Address - Phone:517-849-7040
Practice Address - Fax:517-849-7050
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILM004006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C857070OtherBCBS
MIM94500006Medicare PIN