Provider Demographics
NPI:1285396689
Name:CODDINGTON, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CODDINGTON
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 1:6740 W 6 RD
Mailing Address - Street 2:
Mailing Address - City:MESICK
Mailing Address - State:MI
Mailing Address - Zip Code:49668-9338
Mailing Address - Country:US
Mailing Address - Phone:231-429-0646
Mailing Address - Fax:231-935-7528
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-6698
Practice Address - Fax:231-935-7528
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI03826122246QC2700X
MI7501008667225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No246QC2700XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyCytotechnology