Provider Demographics
NPI:1063774024
Name:DITE, LISA LYNN
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LYNN
Last Name:DITE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:LYNN
Other - Last Name:GREMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6375 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-7416
Mailing Address - Country:US
Mailing Address - Phone:315-335-4761
Mailing Address - Fax:
Practice Address - Street 1:130 LOMOND CT
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5951
Practice Address - Country:US
Practice Address - Phone:315-724-4286
Practice Address - Fax:315-724-4170
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency