Provider Demographics
NPI:1083706634
Name:PEZZOLLA, LISA FETTINGER
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:FETTINGER
Last Name:PEZZOLLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 KNOX CAVE ROAD
Mailing Address - Street 2:
Mailing Address - City:DELANSON
Mailing Address - State:NY
Mailing Address - Zip Code:12053
Mailing Address - Country:US
Mailing Address - Phone:518-872-9890
Mailing Address - Fax:
Practice Address - Street 1:334 KRUMKILL ROAD
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9303
Practice Address - Country:US
Practice Address - Phone:518-459-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor