Healthcare Provider Details

I. General information

NPI: 1134423114
Provider Name (Legal Business Name): LISA L LARSEN L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 WYOMING BLVD NE
ALBUQUERQUE NM
87111-4540
US

IV. Provider business mailing address

2403 SAN MATEO BLVD NE W-16
ALBUQUERQUE NM
87110-4058
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-5486
  • Fax:
Mailing address:
  • Phone: 505-363-6718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4655
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: