Provider Demographics
NPI:1376999169
Name:TATOM, LISA (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TATOM
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 1:319 W 50TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79764-4115
Mailing Address - Country:US
Mailing Address - Phone:432-638-2653
Mailing Address - Fax:432-614-9650
Practice Address - Street 1:319 W 50TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79764-4115
Practice Address - Country:US
Practice Address - Phone:432-638-2653
Practice Address - Fax:432-614-9650
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT122817225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist