Provider Demographics
NPI:1013034305
Name:MAIN, LISA ANNE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:MAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BANK ST
Mailing Address - Street 2:
Mailing Address - City:LEROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482
Mailing Address - Country:US
Mailing Address - Phone:585-768-1980
Mailing Address - Fax:
Practice Address - Street 1:15 BANK ST
Practice Address - Street 2:
Practice Address - City:LEROY
Practice Address - State:NY
Practice Address - Zip Code:14482
Practice Address - Country:US
Practice Address - Phone:585-768-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012286-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist