Provider Demographics
NPI:1407547300
Name:KERN, LISA MARIE (MT, BCTMB)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KERN
Suffix:
Gender:F
Credentials:MT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 CASA RUFINA RD UNIT 222
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-8304
Mailing Address - Country:US
Mailing Address - Phone:505-316-6325
Mailing Address - Fax:
Practice Address - Street 1:524 W CORDOVA RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1822
Practice Address - Country:US
Practice Address - Phone:505-316-6325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4208225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist