Provider Demographics
NPI:1912545658
Name:REAVLEY, LISA ANN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:REAVLEY
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 152
Mailing Address - Street 2:
Mailing Address - City:CEDAR GLEN
Mailing Address - State:CA
Mailing Address - Zip Code:92321-0152
Mailing Address - Country:US
Mailing Address - Phone:909-767-5686
Mailing Address - Fax:
Practice Address - Street 1:27215 UNIT B HWY 189
Practice Address - Street 2:
Practice Address - City:BLUE JAY
Practice Address - State:CA
Practice Address - Zip Code:92317
Practice Address - Country:US
Practice Address - Phone:909-767-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73153225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty