Provider Demographics
NPI:1093706384
Name:SANDERSON, LISA LYNNE (MS, PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LYNNE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01035-9558
Mailing Address - Country:US
Mailing Address - Phone:413-586-5552
Mailing Address - Fax:413-586-3330
Practice Address - Street 1:241 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-9558
Practice Address - Country:US
Practice Address - Phone:413-586-5552
Practice Address - Fax:413-586-3330
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15956225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASA Y69376Medicare ID - Type UnspecifiedPHYSICAL THERAPIST