Healthcare Provider Details

I. General information

NPI: 1891967543
Provider Name (Legal Business Name): LISA CHRISTINE KAZMAR LPTA, LMTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 11/30/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1917 OLD HWY 66
EDGEWOOD NM
87015
US

IV. Provider business mailing address

PO BOX 2227
EDGEWOOD NM
87015-2227
US

V. Phone/Fax

Practice location:
  • Phone: 505-917-3631
  • Fax:
Mailing address:
  • Phone: 505-917-3631
  • Fax: 505-281-4997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0575
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT9403
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: