Healthcare Provider Details

I. General information

NPI: 1740442912
Provider Name (Legal Business Name): LISA JUANITA WILSON CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W MICHIGAN ST SUITE# 5
MOUNT PLEASANT MI
48858-2492
US

IV. Provider business mailing address

304 W MICHIGAN ST SUITE# 5
MOUNT PLEASANT MI
48858-2492
US

V. Phone/Fax

Practice location:
  • Phone: 989-572-8117
  • Fax:
Mailing address:
  • Phone: 989-572-8117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: