Provider Demographics
NPI:1760635668
Name:PETRICONE, LISE (PT)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:
Last Name:PETRICONE
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 1:21 BURD ST
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-3205
Mailing Address - Country:US
Mailing Address - Phone:845-353-2350
Mailing Address - Fax:845-353-2397
Practice Address - Street 1:21 BURD ST
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3205
Practice Address - Country:US
Practice Address - Phone:845-353-2350
Practice Address - Fax:845-353-2397
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009027-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics