Provider Demographics
NPI:1235524356
Name:MATTESON, LISA SPIRIT (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SPIRIT
Last Name:MATTESON
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 1:13509 COPPER AVE NE APT 4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1746
Mailing Address - Country:US
Mailing Address - Phone:505-269-8542
Mailing Address - Fax:
Practice Address - Street 1:13509 COPPER AVE NE APT 4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-1746
Practice Address - Country:US
Practice Address - Phone:505-269-8542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7793111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation