Provider Demographics
NPI:1649318528
Name:SELK, LISA ANN (LMP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:SELK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5919 45TH ST. CT. E.
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98443
Mailing Address - Country:US
Mailing Address - Phone:253-926-1151
Mailing Address - Fax:
Practice Address - Street 1:4111 S MERIDIAN STE F
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5973
Practice Address - Country:US
Practice Address - Phone:253-241-1847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA19020225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist