Provider Demographics
NPI:1588942577
Name:KING, LISA (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 US ROUTE 1
Mailing Address - Street 2:UNIT 26
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9052
Mailing Address - Country:US
Mailing Address - Phone:207-415-6458
Mailing Address - Fax:
Practice Address - Street 1:153 US ROUTE 1
Practice Address - Street 2:UNIT 26
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9052
Practice Address - Country:US
Practice Address - Phone:207-415-6458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT348225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist