Provider Demographics
NPI:1467757732
Name:GRAHAM, LISA MARIE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1489 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:CAMANO ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98282-8810
Mailing Address - Country:US
Mailing Address - Phone:360-661-6583
Mailing Address - Fax:
Practice Address - Street 1:325 E GEORGE HOPPER RD
Practice Address - Street 2:#106
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-3154
Practice Address - Country:US
Practice Address - Phone:360-707-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00015542174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 00015542OtherMASSAGE PRACTITIONER LICENSE