Healthcare Provider Details

I. General information

NPI: 1336113844
Provider Name (Legal Business Name): LISA M HARDY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 SPEAR ST 140 PATRICK GYM
BURLINGTON VT
05405-1701
US

IV. Provider business mailing address

363 ETHAN ALLEN AVE APT. 104
COLCHESTER VT
05446-3319
US

V. Phone/Fax

Practice location:
  • Phone: 269-998-5571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104.0068930
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: