Provider Demographics
NPI:1417087560
Name:MASTRIANO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MASTRIANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 SEA HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06471-1412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 DOUBLE BEACH RD
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-4909
Practice Address - Country:US
Practice Address - Phone:203-315-7638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist