Provider Demographics
NPI:1821164393
Name:DISTASIO, LYNN MARIE (LPT)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:DISTASIO
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:MARIE
Other - Last Name:BUTCZYNSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPT
Mailing Address - Street 1:1086 ROUTE 315
Mailing Address - Street 2:PRO REHABILITATION SERVICES
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18702
Mailing Address - Country:US
Mailing Address - Phone:570-823-7761
Mailing Address - Fax:570-822-8033
Practice Address - Street 1:1086 ROUTE 315
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-823-7761
Practice Address - Fax:570-822-8033
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006913L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
076541OtherFIRST PRIORITY
0661771OtherBLUE SHIELD
442518OtherHEALTH AMERICA ASSURANCE
442539OtherHEALTH AMERICA ASSURANCE
815826OtherFIRST PRIORITY
813831OtherFIRST PRIORITY
397908OtherHEALTH AMERICA ASSURANCE