Provider Demographics
NPI:1104129527
Name:WOURMS, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WOURMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2238
Mailing Address - Country:US
Mailing Address - Phone:320-760-4342
Mailing Address - Fax:
Practice Address - Street 1:1121 WESTRAC DR S STE 102
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2385
Practice Address - Country:US
Practice Address - Phone:701-297-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1144225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist