Provider Demographics
NPI:1730412453
Name:TRAINOR, LISA DESHA (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DESHA
Last Name:TRAINOR
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 1:6213 NW KUKUI CT
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3346
Mailing Address - Country:US
Mailing Address - Phone:772-418-2751
Mailing Address - Fax:
Practice Address - Street 1:3720 SE JENNINGS RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7701
Practice Address - Country:US
Practice Address - Phone:772-398-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21741225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant