Provider Demographics
NPI:1902043003
Name:GRAZIANO, LISA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GRAZIANO
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 1:344 STAPLES ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4260
Mailing Address - Country:US
Mailing Address - Phone:516-790-6628
Mailing Address - Fax:
Practice Address - Street 1:1050 STEWART AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4888
Practice Address - Country:US
Practice Address - Phone:516-505-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-11
Last Update Date:2009-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016636OtherPHYSICAL THERAPY LICENSE NUMBER