Provider Demographics
NPI:1497203202
Name:LISITANO, ERIC (PT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:LISITANO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-2765
Mailing Address - Country:US
Mailing Address - Phone:860-919-8685
Mailing Address - Fax:
Practice Address - Street 1:305 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-2765
Practice Address - Country:US
Practice Address - Phone:860-919-8685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist