Provider Demographics
NPI:1073757886
Name:VIDAKOVIC, LISA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:VIDAKOVIC
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 1:1343 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-2461
Mailing Address - Country:US
Mailing Address - Phone:814-315-2548
Mailing Address - Fax:814-456-6060
Practice Address - Street 1:1343 W 38TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-2461
Practice Address - Country:US
Practice Address - Phone:814-315-2548
Practice Address - Fax:814-456-6060
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPTO17348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist