Provider Demographics
NPI:1336105857
Name:PICKETT, LISA M (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:PICKETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:845 N MAIN ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5700
Mailing Address - Country:US
Mailing Address - Phone:401-270-1905
Mailing Address - Fax:401-270-5658
Practice Address - Street 1:845 N MAIN ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5700
Practice Address - Country:US
Practice Address - Phone:401-270-1905
Practice Address - Fax:401-270-5658
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI31559OtherNHPRI
RILP61461OtherRITE SHARE COPAY PROVIDER
RI411184OtherBLUE CHIP
RIPT01811OtherSTATE LICENSE
RI31245-9OtherBLUE CROSS BLUE SHIELD
RI411184OtherBLUE CHIP