Provider Demographics
NPI:1508000795
Name:ST. PETER, LISA (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:ST. PETER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BOUCHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:12 BELANGER RD
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-4023
Mailing Address - Country:US
Mailing Address - Phone:207-498-2807
Mailing Address - Fax:
Practice Address - Street 1:163 VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-3567
Practice Address - Country:US
Practice Address - Phone:207-498-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist