Provider Demographics
NPI:1841332525
Name:WOLF, LISA ANN (MPT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:WOLF
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HUDSON DR
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-4419
Mailing Address - Country:US
Mailing Address - Phone:631-269-6196
Mailing Address - Fax:
Practice Address - Street 1:77 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE 5
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3410
Practice Address - Country:US
Practice Address - Phone:631-499-4344
Practice Address - Fax:631-499-4383
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0162532251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics