Provider Demographics
NPI:1336113844
Name:HARDY, LISA M (ATC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HARDY
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 1:363 ETHAN ALLEN AVE
Mailing Address - Street 2:APT. 104
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-3319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:97 SPEAR ST
Practice Address - Street 2:140 PATRICK GYM
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-1701
Practice Address - Country:US
Practice Address - Phone:269-998-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.00689302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer