Provider Demographics
NPI:1700901261
Name:BLACKBURN, LISA G (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 LYME RD STE 210
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-1222
Mailing Address - Country:US
Mailing Address - Phone:603-277-9784
Mailing Address - Fax:443-926-5980
Practice Address - Street 1:45 LYME RD STE 210
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-1222
Practice Address - Country:US
Practice Address - Phone:603-277-9784
Practice Address - Fax:443-926-5980
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00B331R67Medicare ID - Type Unspecified