Provider Demographics
NPI:1629212733
Name:DEFOSSE, LISA (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DEFOSSE
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:PO BOX 2048
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-2048
Mailing Address - Country:US
Mailing Address - Phone:207-893-0033
Mailing Address - Fax:207-893-1211
Practice Address - Street 1:108 TANDBERG TRAIL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062
Practice Address - Country:US
Practice Address - Phone:207-893-0033
Practice Address - Fax:207-893-1211
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT2834225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist