Provider Demographics
NPI:1265700934
Name:LAGRANGE, AMY DIANE (LMT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:DIANE
Last Name:LAGRANGE
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 1:933 BRADBURY SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4301
Mailing Address - Country:US
Mailing Address - Phone:505-272-2521
Mailing Address - Fax:505-272-3238
Practice Address - Street 1:4700 JEFFERSON ST NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2136
Practice Address - Country:US
Practice Address - Phone:505-925-7464
Practice Address - Fax:505-925-4539
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4833225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist