Provider Demographics
NPI:1114449741
Name:TAKASHINA, LISE (LAC)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:
Last Name:TAKASHINA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1724
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1724
Mailing Address - Country:US
Mailing Address - Phone:208-292-4829
Mailing Address - Fax:
Practice Address - Street 1:302 N 5TH ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2814
Practice Address - Country:US
Practice Address - Phone:831-332-0587
Practice Address - Fax:831-332-0587
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-336171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist