Provider Demographics
NPI:1649777657
Name:LETTS, LISA MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:LETTS
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 1:410 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1324
Mailing Address - Country:US
Mailing Address - Phone:269-455-0571
Mailing Address - Fax:
Practice Address - Street 1:410 ERIE ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1324
Practice Address - Country:US
Practice Address - Phone:269-455-0571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-07
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501005683225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty