Healthcare Provider Details

I. General information

NPI: 1003292509
Provider Name (Legal Business Name): LISA KELLEY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MACVANE LMT

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 FREE STREET C/O HEADGAMES SPA
PORTLAND ME
04106
US

IV. Provider business mailing address

268 PREBLE ST UNIT B
SOUTH PORTLAND ME
04106-2232
US

V. Phone/Fax

Practice location:
  • Phone: 207-239-9485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberMT4261
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: