Provider Demographics
NPI:1962012062
Name:SOVIS, LORI LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
Last Name:SOVIS
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 1:4134 BURLINGAME AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-3725
Mailing Address - Country:US
Mailing Address - Phone:616-302-3293
Mailing Address - Fax:
Practice Address - Street 1:535 GREENWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2901
Practice Address - Country:US
Practice Address - Phone:616-635-1267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003456225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty