Healthcare Provider Details

I. General information

NPI: 1972822807
Provider Name (Legal Business Name): LISA MARIE THEROUX P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 HALL ST SUITE H
CONCORD NH
03301-3478
US

IV. Provider business mailing address

90 EASTERN AVE UNIT 302
MANCHESTER NH
03104-6644
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-4540
  • Fax:
Mailing address:
  • Phone: 603-935-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3523
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: