Provider Demographics
NPI:1831565902
Name:BIVENS, LISA (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BIVENS
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 1:1268 FLYING W LN
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-5726
Mailing Address - Country:US
Mailing Address - Phone:540-797-5851
Mailing Address - Fax:540-369-6261
Practice Address - Street 1:1310 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5219
Practice Address - Country:US
Practice Address - Phone:540-797-5851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019010885225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist