Provider Demographics
NPI:1063481653
Name:BURDICK, LISA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BURDICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 MALLETT DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-1312
Mailing Address - Country:US
Mailing Address - Phone:207-442-0325
Mailing Address - Fax:207-443-4578
Practice Address - Street 1:45 MALLETT DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-1312
Practice Address - Country:US
Practice Address - Phone:207-442-0325
Practice Address - Fax:207-443-4578
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2433225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431972299Medicaid