Provider Demographics
NPI:1306065933
Name:HAGLUND, LISA AMON (LMP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:AMON
Last Name:HAGLUND
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:LAURISA
Other - Middle Name:ANN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:3773 MARTIN WAY E
Mailing Address - Street 2:SUITE 102C
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-357-9176
Mailing Address - Fax:
Practice Address - Street 1:3773 MARTIN WAY E
Practice Address - Street 2:SUITE 102 C
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-459-9780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006546172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00006546OtherWASH STATE HEALTH DEPT