Provider Demographics
NPI:1215981105
Name:LUSSIER, ELIZA G (MSPT)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:G
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:B
Other - Last Name:GRANNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:945 SAWYER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6535
Mailing Address - Country:US
Mailing Address - Phone:207-233-9272
Mailing Address - Fax:207-221-1063
Practice Address - Street 1:945 SAWYER ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6535
Practice Address - Country:US
Practice Address - Phone:207-233-9272
Practice Address - Fax:207-221-1063
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432181399Medicaid
MEPENDINGMedicare ID - Type Unspecified