Basic Information
| Provider Information | |||||||||
| NPI: | 1912997271 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIVIAN | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | R.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 E COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011052509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133016019 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 933 E COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011052509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133016019 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5487 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 007615 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0365611 | 05 | MA | MEDICAID | Y66095 | 01 | MA | BLUECROSS/BLUESHIELD | OTHER |