Provider Demographics
NPI:1588006936
Name:RANDBERG, LISA ANN (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:RANDBERG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 DEBBIE LEE LN
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-3803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:631-175-8030
Practice Address - Street 1:56 DEBBIE LEE LN
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-3803
Practice Address - Country:US
Practice Address - Phone:631-751-8000
Practice Address - Fax:631-175-8030
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016262-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist