Provider Demographics
NPI:1982015905
Name:KING, LISA D (LMT, RYT)
Entity Type:Individual
Prefix:
First Name:LISA D
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LMT, RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 MAIN ST STE 7&8
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-3127
Mailing Address - Country:US
Mailing Address - Phone:860-440-6418
Mailing Address - Fax:
Practice Address - Street 1:321 MAIN ST STE 7&8
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-3127
Practice Address - Country:US
Practice Address - Phone:860-440-6418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist