MEDICARE: MS. LISA L LARSEN L.M.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	4655	NM

General Provider Information

NPI Number	:	1134423114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA L LARSEN L.M.T.

Provider Business Mailing Address
First Line	:	2403 SAN MATEO BLVD NE
Second Line	:	W-16
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4058
Country	:	US
Telephone Number	:	505-363-6718
Fax Number	:

Provider Business Practice Location Address
First Line	:	2709 WYOMING BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-4540
Country	:	US
Telephone Number	:	505-294-5486
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2011
Last Update Date	:	01/05/2011

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