Provider Demographics
NPI:1235775768
Name:VICENCIO, LISA ANN (ATC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:VICENCIO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2637
Mailing Address - Country:US
Mailing Address - Phone:518-564-4152
Mailing Address - Fax:518-564-2558
Practice Address - Street 1:101 BROAD ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2637
Practice Address - Country:US
Practice Address - Phone:518-564-4152
Practice Address - Fax:518-564-2558
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000682-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer