Healthcare Provider Details

I. General information

NPI: 1003218462
Provider Name (Legal Business Name): ADAM PETER LISEWSKI OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 BOSTON POST RD
WEST HAVEN CT
06516-2043
US

IV. Provider business mailing address

2933 LAKE JAMES DR APT 202
FUQUAY VARINA NC
27526-3920
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax:
Mailing address:
  • Phone: 120-330-5148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number6619
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: