Provider Demographics
NPI:1174236905
Name:BLACKMER, LISA (DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BLACKMER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2863 SNYDER LOOP
Mailing Address - Street 2:
Mailing Address - City:GRAYSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37338-6402
Mailing Address - Country:US
Mailing Address - Phone:815-262-2959
Mailing Address - Fax:
Practice Address - Street 1:360 DELL TRL
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:TN
Practice Address - Zip Code:37327
Practice Address - Country:US
Practice Address - Phone:423-949-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist