Basic Information
| Provider Information | |||||||||
| NPI: | 1629058532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELDERES | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 625 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245516 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 672 NAFF RD | ||||||||
| Address2: | |||||||||
| City: | BOONES MILL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240651992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409859813 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 9875 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225100000X | 2305204677 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.