Provider Demographics
NPI:1083813679
Name:DIBENEDETTO, LISA MARIE (MSPT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:DIBENEDETTO
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W G ST APT 432
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5944
Mailing Address - Country:US
Mailing Address - Phone:617-827-2343
Mailing Address - Fax:
Practice Address - Street 1:820 W G ST APT 432
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5944
Practice Address - Country:US
Practice Address - Phone:617-827-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist