Provider Demographics
NPI:1568897478
Name:KRISTOFFERSEN, LISA M (LMT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:KRISTOFFERSEN
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 1:11 S LAKE ST # 3
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1511
Mailing Address - Country:US
Mailing Address - Phone:847-693-1515
Mailing Address - Fax:
Practice Address - Street 1:11 S LAKE ST # 3
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1511
Practice Address - Country:US
Practice Address - Phone:847-693-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.010659225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist