Provider Demographics
NPI:1447454350
Name:BRENNAN, LISA MAISCH (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MAISCH
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:MAISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:805 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2055
Mailing Address - Country:US
Mailing Address - Phone:618-281-6538
Mailing Address - Fax:
Practice Address - Street 1:3520 CHOUTEAU AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2916
Practice Address - Country:US
Practice Address - Phone:314-771-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117973225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant