Provider Demographics
NPI:1639196538
Name:DIEBOLD, LISA (MSPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DIEBOLD
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-789-2845
Mailing Address - Fax:
Practice Address - Street 1:10 HIGH ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3144
Practice Address - Country:US
Practice Address - Phone:401-783-8077
Practice Address - Fax:401-789-6029
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT1309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412405OtherRI BLUE CHIP
RI11440422OtherCAQH
RI11440422OtherCAQH