Healthcare Provider Details

I. General information

NPI: 1912027160
Provider Name (Legal Business Name): LISA JOSUPAIT MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 RALPH JUDD COURT
AURORA IL
60506
US

IV. Provider business mailing address

1377 MOTOR PKWY STE 307
ISLANDIA NY
11749-5258
US

V. Phone/Fax

Practice location:
  • Phone: 630-466-2083
  • Fax:
Mailing address:
  • Phone: 631-580-5200
  • Fax: 631-580-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070012467
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: