Basic Information
| Provider Information | |||||||||
| NPI: | 1235507039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIS | ||||||||
| FirstName: | MAXINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT, DPT | ||||||||
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| OtherLastName: | MITJANS | ||||||||
| OtherFirstName: | MAXINE | ||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY | ||||||||
| Address2: | STE 307 | ||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Practice Location | |||||||||
| Address1: | 176 ROUTE 70 | ||||||||
| Address2: | SUITE 37 | ||||||||
| City: | MEDFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080558704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6097147733 | ||||||||
| FaxNumber: | 6097147750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2015 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01619100 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.