Basic Information
| Provider Information | |||||||||
| NPI: | 1063466308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIZOTTE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 RESERVOIR AVE | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019464250 | ||||||||
| FaxNumber: | 4012755645 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 RESERVOIR AVE | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019464250 | ||||||||
| FaxNumber: | 4012755645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA00318 | RI | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225700000X | MT00964 | RI | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | MT00964 | 01 | RI | MASSAGE THERAPY LICENSE | OTHER | PTA00318 | 01 | RI | PHYSICAL THERAPY ASST. LC | OTHER |