MEDICARE: MS. LISA MARIE PORTIS DPT

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	PT02938	RI

General Provider Information

NPI Number	:	1770935512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA MARIE PORTIS DPT

Provider Business Mailing Address
First Line	:	2 NEWPORT AVE # 1
Second Line	:
City	:	NEWPORT
State	:	RI
Zip	:	02840-2149
Country	:	US
Telephone Number	:	207-313-3655
Fax Number	:

Provider Business Practice Location Address
First Line	:	1454 S COUNTY TRL
Second Line	:
City	:	EAST GREENWICH
State	:	RI
Zip	:	02818-1749
Country	:	US
Telephone Number	:	401-444-2050
Fax Number	:

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

Provider Enumeration Date	:	07/05/2016
Last Update Date	:	08/19/2016

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