Provider Demographics
NPI:1366728651
Name:FAURE, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:FAURE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:22150 N 20TH ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-5608
Mailing Address - Country:US
Mailing Address - Phone:480-262-1037
Mailing Address - Fax:
Practice Address - Street 1:22150 N 20TH ST
Practice Address - Street 2:SUITE 109
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-5608
Practice Address - Country:US
Practice Address - Phone:480-262-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-13161225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist