Provider Demographics
NPI:1659634392
Name:GROSS, LISA LORRAINE (LMP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LORRAINE
Last Name:GROSS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LORRAINE
Other - Last Name:WALDBILLIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-0483
Mailing Address - Country:US
Mailing Address - Phone:360-698-3140
Mailing Address - Fax:360-698-1441
Practice Address - Street 1:3595 NW BUCKLIN HILL RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8503
Practice Address - Country:US
Practice Address - Phone:360-698-3140
Practice Address - Fax:360-698-1441
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60264809225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist