Provider Demographics
NPI:1114245628
Name:MAFFUCCI, LISA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MAFFUCCI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5254 W 137TH ST
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6420
Mailing Address - Country:US
Mailing Address - Phone:310-643-5055
Mailing Address - Fax:
Practice Address - Street 1:5254 W 137TH ST
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-6420
Practice Address - Country:US
Practice Address - Phone:310-643-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP57538Medicare UPIN
WPT22439BMedicare PIN