MEDICARE: LISA DAMICO PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	40QB00046100	NJ

General Provider Information

NPI Number	:	1023470341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DAMICO PTA

Provider Business Mailing Address
First Line	:	4 CEDAR CREST DR
Second Line	:
City	:	POMPTON PLAINS
State	:	NJ
Zip	:	07444-2161
Country	:	US
Telephone Number	:	973-831-3672
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 CEDAR CREST DR
Second Line	:
City	:	POMPTON PLAINS
State	:	NJ
Zip	:	07444-2161
Country	:	US
Telephone Number	:	973-831-3672
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2016
Last Update Date	:	03/25/2016

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