Provider Demographics
NPI:1457444770
Name:VAN ZILEN, LISA M (MSPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:VAN ZILEN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:KNOWLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:2408 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3209
Mailing Address - Country:US
Mailing Address - Phone:203-626-0160
Mailing Address - Fax:203-294-6734
Practice Address - Street 1:701 N COLONY RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2407
Practice Address - Country:US
Practice Address - Phone:203-294-0449
Practice Address - Fax:203-466-8527
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7312225100000X
CT007312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
080007312OtherANTHEM BCBS ID