Basic Information
| Provider Information | |||||||||
| NPI: | 1821164393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISTASIO | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUTCZYNSKI | ||||||||
| OtherFirstName: | LYNN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LPT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1086 ROUTE 315 | ||||||||
| Address2: | PRO REHABILITATION SERVICES | ||||||||
| City: | PLAINS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708237761 | ||||||||
| FaxNumber: | 5708228033 | ||||||||
| Practice Location | |||||||||
| Address1: | 1086 ROUTE 315 | ||||||||
| Address2: | |||||||||
| City: | PLAINS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708237761 | ||||||||
| FaxNumber: | 5708228033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PT006913L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 076541 | 01 | FIRST PRIORITY | OTHER | 0661771 | 01 | BLUE SHIELD | OTHER | 442518 | 01 | HEALTH AMERICA ASSURANCE | OTHER | 442539 | 01 | HEALTH AMERICA ASSURANCE | OTHER | 815826 | 01 | FIRST PRIORITY | OTHER | 813831 | 01 | FIRST PRIORITY | OTHER | 397908 | 01 | HEALTH AMERICA ASSURANCE | OTHER |