Provider Demographics
NPI:1093778904
Name:CANTARA, LISA MARIE (MS, ATC, CSCS)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:CANTARA
Suffix:
Gender:F
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 OLD TOWN RD
Mailing Address - Street 2:24F
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2200
Mailing Address - Country:US
Mailing Address - Phone:631-474-4908
Mailing Address - Fax:631-632-3231
Practice Address - Street 1:100 NICOLLS RD
Practice Address - Street 2:SBU, ISC
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-3500
Practice Address - Country:US
Practice Address - Phone:631-632-7709
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer