Provider Demographics
NPI:1497790836
Name:FAVREAU, LISA (ATC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FAVREAU
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FODEN RD
Mailing Address - Street 2:SUITE 103W
Mailing Address - City:SO PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2319
Mailing Address - Country:US
Mailing Address - Phone:207-772-2625
Mailing Address - Fax:207-879-4246
Practice Address - Street 1:100 FODEN RD
Practice Address - Street 2:SUITE 103W
Practice Address - City:SO PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2319
Practice Address - Country:US
Practice Address - Phone:207-772-2625
Practice Address - Fax:207-879-4246
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEAT2632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer