Provider Demographics
NPI:1801854336
Name:SEIDE, LISA PAIGE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:PAIGE
Last Name:SEIDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:PAIGE
Other - Last Name:SAMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:475 NORTHERN BLVD
Mailing Address - Street 2:SUITE 29
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4819
Mailing Address - Country:US
Mailing Address - Phone:516-829-0030
Mailing Address - Fax:516-466-7723
Practice Address - Street 1:475 NORTHERN BLVD
Practice Address - Street 2:SUITE 11
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4819
Practice Address - Country:US
Practice Address - Phone:516-829-0030
Practice Address - Fax:516-466-7723
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0129231225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ43821OtherEMPIRE BCBS
NYQ43821OtherEMPIRE BCBS