Provider Demographics
NPI:1730328600
Name:MUMFORD, LISA BOURBEAU (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BOURBEAU
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6209 PEARL LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3341
Mailing Address - Country:US
Mailing Address - Phone:619-261-3177
Mailing Address - Fax:
Practice Address - Street 1:833 BROADWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-4668
Practice Address - Country:US
Practice Address - Phone:619-447-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 20702225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 20702OtherPHYSICAL THERAPY