Provider Demographics
NPI:1922047430
Name:ELLISON, LISA M (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:BOTASH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:45 ROGERS DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-4403
Mailing Address - Country:US
Mailing Address - Phone:585-429-7551
Mailing Address - Fax:585-429-7551
Practice Address - Street 1:1854 STONE ROAD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14615
Practice Address - Country:US
Practice Address - Phone:585-581-0300
Practice Address - Fax:585-581-0365
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0103931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist