Provider Demographics
NPI:1184707754
Name:BAUMGART, LISA M (MPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BAUMGART
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WILLIAMSTOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:LANESBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01237
Mailing Address - Country:US
Mailing Address - Phone:413-442-7007
Mailing Address - Fax:413-442-7011
Practice Address - Street 1:55 WILLIAMSTOWN ROAD
Practice Address - Street 2:
Practice Address - City:LANESBORO
Practice Address - State:MA
Practice Address - Zip Code:01237
Practice Address - Country:US
Practice Address - Phone:413-442-7007
Practice Address - Fax:413-442-7011
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000000038656OtherBMC HEALTHNET
MA40193OtherHEALTH NEW ENGLAND
MAY68083OtherBLUE CROSS BLUE SHIELD
MA5978465OtherCIGNA
MA0711683Medicaid
MA637747OtherTUFTS
MAY68879Medicare ID - Type Unspecified