Provider Demographics
NPI:1780875450
Name:WONG, LISA MARIE (ATC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:WONG
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3497 PATCON WAY
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-3863
Mailing Address - Country:US
Mailing Address - Phone:614-771-5760
Mailing Address - Fax:
Practice Address - Street 1:4775 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4313
Practice Address - Country:US
Practice Address - Phone:614-442-5557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0027712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer