Provider Demographics
NPI:1063005072
Name:WORTMAN, LISA LOUISE (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LOUISE
Last Name:WORTMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E MENDENHALL ST # A
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3820
Mailing Address - Country:US
Mailing Address - Phone:406-920-0614
Mailing Address - Fax:
Practice Address - Street 1:810 N WALLACE AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3020
Practice Address - Country:US
Practice Address - Phone:406-920-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2960225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist