Healthcare Provider Details

I. General information

NPI: 1952608853
Provider Name (Legal Business Name): LISA NADA GLINES L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2011
Last Update Date: 02/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 SLIGO RD
NORTH YARMOUTH ME
04097-6207
US

IV. Provider business mailing address

747 SLIGO RD
NORTH YARMOUTH ME
04097-6207
US

V. Phone/Fax

Practice location:
  • Phone: 603-630-4261
  • Fax:
Mailing address:
  • Phone: 603-630-4261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT4527
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: