Provider Demographics
NPI:1255986915
Name:BREKKE, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BREKKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MAYBROOK RD STE N
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2741
Mailing Address - Country:US
Mailing Address - Phone:845-636-4344
Mailing Address - Fax:845-636-4355
Practice Address - Street 1:69 SAND PIT RD STE 201
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4004
Practice Address - Country:US
Practice Address - Phone:203-748-5631
Practice Address - Fax:203-207-3194
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12376225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist