Provider Demographics
NPI:1003292509
Name:KELLEY, LISA (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MACVANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:268 PREBLE ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 FREE STREET
Practice Address - Street 2:C/O HEADGAMES SPA
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-239-9485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4261175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath