Provider Demographics
NPI:1992724850
Name:STAM, LISA LARAE
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LARAE
Last Name:STAM
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 1:17906 SE 16TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683
Mailing Address - Country:US
Mailing Address - Phone:360-608-1806
Mailing Address - Fax:360-253-3047
Practice Address - Street 1:410 E 20TH ST
Practice Address - Street 2:SUITE #7
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663
Practice Address - Country:US
Practice Address - Phone:360-608-1806
Practice Address - Fax:360-253-3047
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00019362225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist