Provider Demographics
NPI:1376566752
Name:BEAUDRY, LISA DANETTE (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DANETTE
Last Name:BEAUDRY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 FAIRMOUNT AVE
Mailing Address - Street 2:JAMESTOWN
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-2609
Mailing Address - Country:US
Mailing Address - Phone:716-665-1166
Mailing Address - Fax:866-902-1160
Practice Address - Street 1:774 FAIRMOUNT AVE
Practice Address - Street 2:JAMESTOWN
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2609
Practice Address - Country:US
Practice Address - Phone:716-665-1166
Practice Address - Fax:866-902-1160
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02163564Medicaid
P30397Medicare UPIN
NYAA0830Medicare ID - Type Unspecified
NY02163564Medicaid