Provider Demographics
NPI:1619399912
Name:GRONDIN, LISA (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRONDIN
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 1:100 GRAY RD
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-2018
Mailing Address - Country:US
Mailing Address - Phone:207-747-5363
Mailing Address - Fax:
Practice Address - Street 1:100 GRAY RD
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-2018
Practice Address - Country:US
Practice Address - Phone:207-747-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT5180225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist