Provider Demographics
NPI:1164568663
Name:SCIALLA, LISA M (DPT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:SCIALLA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:SCIALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:64 BROOKS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-1508
Mailing Address - Country:US
Mailing Address - Phone:617-968-3999
Mailing Address - Fax:
Practice Address - Street 1:33 POND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7163
Practice Address - Country:US
Practice Address - Phone:617-325-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y68632Medicare PIN