Provider Demographics
NPI:1235507039
Name:LIS, MAXINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:LIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MAXINE
Other - Middle Name:
Other - Last Name:MITJANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1377 MOTOR PKWY
Mailing Address - Street 2:STE 307
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5249
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:176 ROUTE 70
Practice Address - Street 2:SUITE 37
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-8704
Practice Address - Country:US
Practice Address - Phone:609-714-7733
Practice Address - Fax:609-714-7750
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01619100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist