Provider Demographics
NPI:1780951269
Name:BADORE, LISA (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BADORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:PINE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:12567-5531
Mailing Address - Country:US
Mailing Address - Phone:518-398-5643
Mailing Address - Fax:
Practice Address - Street 1:50 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:PINE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:12567-5531
Practice Address - Country:US
Practice Address - Phone:518-398-5643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002088-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant