Provider Demographics
NPI:1093051054
Name:CARLSON, LISA MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4213 LEARY WAY NW
Mailing Address - Street 2:#53
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4536
Mailing Address - Country:US
Mailing Address - Phone:206-406-1591
Mailing Address - Fax:
Practice Address - Street 1:11734 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-5026
Practice Address - Country:US
Practice Address - Phone:206-729-1297
Practice Address - Fax:206-440-8453
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012051225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist