Provider Demographics
NPI:1598208118
Name:PEGUERO, LISANDRA
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:PEGUERO
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 1:69 STANWOOD ST APT 1
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-2740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69 STANWOOD ST APT 1
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-2740
Practice Address - Country:US
Practice Address - Phone:617-676-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist