MEDICARE: MS. LISA MARIE DIBENEDETTO MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	33083	CA

General Provider Information

NPI Number	:	1083813679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA MARIE DIBENEDETTO MSPT

Provider Business Mailing Address
First Line	:	820 W G ST APT 432
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-5944
Country	:	US
Telephone Number	:	617-827-2343
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 W G ST APT 432
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-5944
Country	:	US
Telephone Number	:	617-827-2343
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	07/13/2007

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