Provider Demographics
NPI:1356096044
Name:BLUETT, LISA (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BLUETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 TOMLINSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1419
Mailing Address - Country:US
Mailing Address - Phone:646-372-1682
Mailing Address - Fax:
Practice Address - Street 1:1828 TOMLINSON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1419
Practice Address - Country:US
Practice Address - Phone:646-372-1682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist