Provider Demographics
NPI:1114490604
Name:WIDDOWSON, LISA (LMT, CTT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WIDDOWSON
Suffix:
Gender:F
Credentials:LMT, CTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 S 75TH ST
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-2220
Mailing Address - Country:US
Mailing Address - Phone:402-590-9384
Mailing Address - Fax:402-939-0614
Practice Address - Street 1:7200 S 84TH ST STE 140
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-2115
Practice Address - Country:US
Practice Address - Phone:402-915-1590
Practice Address - Fax:402-939-0614
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
173C00000X, 174H00000X
NEG01-370662347C00000X
NE2595225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No174H00000XOther Service ProvidersHealth Educator
No347C00000XTransportation ServicesPrivate Vehicle