Provider Demographics
NPI:1336182617
Name:GENNETT, LISA M (MSPT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:GENNETT
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-0009
Mailing Address - Country:US
Mailing Address - Phone:518-773-2300
Mailing Address - Fax:518-773-2334
Practice Address - Street 1:41 ARTERIAL PLZ
Practice Address - Street 2:SUITE 15B
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-2512
Practice Address - Country:US
Practice Address - Phone:518-773-2300
Practice Address - Fax:518-773-2334
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0263781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0184495Medicaid
NY0184495Medicaid