Provider Demographics
NPI:1215073341
Name:GUCINSKI WATERMAN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GUCINSKI WATERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HOLMEHURST AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4630
Mailing Address - Country:US
Mailing Address - Phone:410-719-0369
Mailing Address - Fax:
Practice Address - Street 1:4000 MITCHELLVILLE RD
Practice Address - Street 2:#400A
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3104
Practice Address - Country:US
Practice Address - Phone:301-805-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD193682251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216532Medicare ID - Type Unspecified