Provider Demographics
NPI:1083046908
Name:GUTHEIL, LISA DIANNE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIANNE
Last Name:GUTHEIL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:DIANNE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:597 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182-2509
Mailing Address - Country:US
Mailing Address - Phone:518-233-0544
Mailing Address - Fax:518-233-0703
Practice Address - Street 1:597 3RD AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-2509
Practice Address - Country:US
Practice Address - Phone:518-233-0544
Practice Address - Fax:518-233-0703
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345963031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist