Provider Demographics
NPI:1194749119
Name:MCCANN, LISA J (LMP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:MCCANN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:25012 104TH AVE SE
Practice Address - Street 2:SUITE C
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-2821
Practice Address - Country:US
Practice Address - Phone:253-856-3477
Practice Address - Fax:253-856-3478
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022741225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist