Provider Demographics
NPI:1083065213
Name:LISEE, CAROLINE (MED, ATC)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:LISEE
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105A STRIBLING AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-2940
Mailing Address - Country:US
Mailing Address - Phone:862-432-2171
Mailing Address - Fax:
Practice Address - Street 1:1 IM SPORTS CIR
Practice Address - Street 2:308 W. CIRCLE DRIVE
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-1049
Practice Address - Country:US
Practice Address - Phone:862-432-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260023692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer