Provider Demographics
NPI:1730267600
Name:FAIRCHILD, LISA (MPT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21111 RED JACKET CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-6444
Mailing Address - Country:US
Mailing Address - Phone:714-742-8238
Mailing Address - Fax:
Practice Address - Street 1:21111 RED JACKET CIR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-6444
Practice Address - Country:US
Practice Address - Phone:714-742-8238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT29159AMedicare PIN