Provider Demographics
NPI:1033218862
Name:CLYNE, LISA SUZANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:SUZANNE
Last Name:CLYNE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 POST RD E
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-5537
Mailing Address - Country:US
Mailing Address - Phone:203-259-2124
Mailing Address - Fax:203-259-2004
Practice Address - Street 1:1300 POST RD E
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-5537
Practice Address - Country:US
Practice Address - Phone:203-259-2124
Practice Address - Fax:203-259-2004
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000908111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3500000734Medicare ID - Type Unspecified
V19910Medicare UPIN