Provider Demographics
NPI:1255978060
Name:LISUM, TERESA LYNN
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:LISUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5261 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44444-1893
Mailing Address - Country:US
Mailing Address - Phone:330-307-7296
Mailing Address - Fax:
Practice Address - Street 1:5261 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:NEWTON FALLS
Practice Address - State:OH
Practice Address - Zip Code:44444-1893
Practice Address - Country:US
Practice Address - Phone:330-307-7296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-30
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer