Provider Demographics
NPI:1710097308
Name:MAZZATTO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MAZZATTO
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 1:140 RIVER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-8129
Mailing Address - Country:US
Mailing Address - Phone:321-267-0033
Mailing Address - Fax:
Practice Address - Street 1:220 N SYKES CREEK PKWY STE 300
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3490
Practice Address - Country:US
Practice Address - Phone:321-459-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA 18541OtherLICENSE #