Provider Demographics
NPI:1912997271
Name:VIVIAN, LISA (RPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VIVIAN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 E COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-2509
Mailing Address - Country:US
Mailing Address - Phone:413-301-6019
Mailing Address - Fax:
Practice Address - Street 1:933 E COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2509
Practice Address - Country:US
Practice Address - Phone:413-301-6019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5487225100000X
CT007615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0365611Medicaid
MAY66095OtherBLUECROSS/BLUESHIELD
MA0365611Medicaid