Provider Demographics
NPI:1124169305
Name:SCHROEDER, LISA ANNE (PT, OCS)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNE
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:PT, OCS
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:CLEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:OAK BLUFFS
Mailing Address - State:MA
Mailing Address - Zip Code:02557-0768
Mailing Address - Country:US
Mailing Address - Phone:310-628-4885
Mailing Address - Fax:213-477-2139
Practice Address - Street 1:7 EAST MEADOW LANE
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557-0768
Practice Address - Country:US
Practice Address - Phone:310-628-4885
Practice Address - Fax:213-477-2139
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA82432251X0800X
CAPT181892251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA8243OtherPHYSICAL THERAPY LICENSE
MA96-11-139-213-000OtherMEDICARE CCN #
CAPT 18189OtherPHYSICAL THERAPY LICENSE