Healthcare Provider Details

I. General information

NPI: 1962735704
Provider Name (Legal Business Name): LISA REDAVID DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 10/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 E 13TH ST
NEW YORK NY
10003-4480
US

IV. Provider business mailing address

8200 E BELLEVIEW AVE SUITE 615E
GREENWOOD VILLAGE CO
80111-2803
US

V. Phone/Fax

Practice location:
  • Phone: 631-298-5367
  • Fax: 631-298-3810
Mailing address:
  • Phone: 303-694-3333
  • Fax: 303-221-4766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number031580-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: