Provider Demographics
NPI:1083653802
Name:PARADISO, LISA DIAN (MPT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DIAN
Last Name:PARADISO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CHANNING WAY
Mailing Address - Street 2:#331
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2638
Mailing Address - Country:US
Mailing Address - Phone:415-491-4605
Mailing Address - Fax:
Practice Address - Street 1:165 ROWLAND WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5038
Practice Address - Country:US
Practice Address - Phone:415-898-1311
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT264582251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT264580Medicare ID - Type UnspecifiedPHYSICAL THERAPY