Provider Demographics
NPI:1780800565
Name:MACCARONE, LISSETTE ARELI
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:ARELI
Last Name:MACCARONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISSETTE
Other - Middle Name:ARELI
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:22218 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-3343
Mailing Address - Country:US
Mailing Address - Phone:310-435-1540
Mailing Address - Fax:
Practice Address - Street 1:22218 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-3343
Practice Address - Country:US
Practice Address - Phone:310-435-1540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT8004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT8004OtherSTATE PTA LIC