1679553200 NPI number — LISA M KONIOWSKY PHYSICAL THERAPIST

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679553200 NPI number — LISA M KONIOWSKY PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONIOWSKY
Provider First Name:
LISA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHANNON
Provider Other First Name:
LISA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679553200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1397 S CANFIELD NILES RD
Provider Second Line Business Mailing Address:
UNIT 1
Provider Business Mailing Address City Name:
YOUNGSTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44515-4084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-953-0129
Provider Business Mailing Address Fax Number:
330-953-0650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44240-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-677-5053
Provider Business Practice Location Address Fax Number:
330-673-8016
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT-010536 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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