Provider Demographics
NPI:1467898775
Name:LIPFORD, ALICE EDENA (NCTMB, WLMT)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:EDENA
Last Name:LIPFORD
Suffix:
Gender:F
Credentials:NCTMB, WLMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 COUNTY ROAD PH
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8519
Mailing Address - Country:US
Mailing Address - Phone:608-781-2555
Mailing Address - Fax:
Practice Address - Street 1:1263 COUNTY ROAD PH
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8519
Practice Address - Country:US
Practice Address - Phone:608-781-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI/57-146OtherSTATE OF WISCONSIN