Provider Demographics
NPI:1053448456
Name:WITHAM, LISA GAY (ATC, LAT)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:GAY
Last Name:WITHAM
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ASPETUCK AVE.
Mailing Address - Street 2:CANTERBURY SCHOOL
Mailing Address - City:NEW MILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:06776
Mailing Address - Country:US
Mailing Address - Phone:860-389-3110
Mailing Address - Fax:
Practice Address - Street 1:226 ROCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-2170
Practice Address - Country:US
Practice Address - Phone:603-425-2989
Practice Address - Fax:603-425-2978
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1247101YM0800X
CT0002802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health