Provider Demographics
NPI:1689119117
Name:SHEPHERSON, LISA MCKELL (DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MCKELL
Last Name:SHEPHERSON
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MCKELL
Other - Last Name:LEAVITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3300N. RUNNING CREEK WAY
Mailing Address - Street 2:B150
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5563
Mailing Address - Country:US
Mailing Address - Phone:801-766-4244
Mailing Address - Fax:801-766-4245
Practice Address - Street 1:3300N. RUNNING CREEK WAY
Practice Address - Street 2:B150
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5563
Practice Address - Country:US
Practice Address - Phone:801-766-4244
Practice Address - Fax:801-766-4245
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10190968-80162251X0800X
UT10190968-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT422390Medicaid