Provider Demographics
NPI:1023060001
Name:LISENBY, MOLLY D (PT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:D
Last Name:LISENBY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5009 N EXECUTIVE DR
Mailing Address - Street 2:STE B
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4866
Mailing Address - Country:US
Mailing Address - Phone:309-472-2413
Mailing Address - Fax:
Practice Address - Street 1:5009 N EXECUTIVE DR STE B
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-839-8631
Practice Address - Fax:855-579-3536
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK08135Medicare PIN