Provider Demographics
NPI:1316345523
Name:BERUBE, LISA-MAREE
Entity type:Individual
Prefix:
First Name:LISA-MAREE
Middle Name:
Last Name:BERUBE
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 1:207 BON TEMPS ROULE
Mailing Address - Street 2:APT 8C
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:561-251-6399
Mailing Address - Fax:
Practice Address - Street 1:207 BON TEMPS ROULE
Practice Address - Street 2:8C
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-2558
Practice Address - Country:US
Practice Address - Phone:561-251-6399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7719225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist