Provider Demographics
NPI:1225375678
Name:MATARAZZO, LISA E (DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:MATARAZZO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 PASSAIC AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:358 PASSAIC AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2737
Practice Address - Country:US
Practice Address - Phone:973-432-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01289700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01289700OtherLICENSE NUMBER