Provider Demographics
NPI:1770921447
Name:DOUGLAS, LISA MARIE (LMT 4600)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LMT 4600
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-2146
Mailing Address - Country:US
Mailing Address - Phone:501-613-1888
Mailing Address - Fax:
Practice Address - Street 1:1421 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2146
Practice Address - Country:US
Practice Address - Phone:501-613-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4600173C00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No173C00000XOther Service ProvidersReflexologist