Provider Demographics
NPI:1003581497
Name:BERTHIAUME, LARA NICOLE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:NICOLE
Last Name:BERTHIAUME
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 STILLINGS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-2824
Mailing Address - Country:US
Mailing Address - Phone:831-246-1367
Mailing Address - Fax:
Practice Address - Street 1:126 STILLINGS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94131-2824
Practice Address - Country:US
Practice Address - Phone:831-246-1367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26275225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist