Provider Demographics
NPI:1336350826
Name:LISTER, SANDRA SUE (LMT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:SUE
Last Name:LISTER
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 1:924 NE 11TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1658
Mailing Address - Country:US
Mailing Address - Phone:541-471-6299
Mailing Address - Fax:
Practice Address - Street 1:980 SW 6TH ST
Practice Address - Street 2:SUITE 25
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2910
Practice Address - Country:US
Practice Address - Phone:541-471-6299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4339174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist