Provider Demographics
NPI:1982060273
Name:CORRIELL, LISA (LMP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CORRIELL
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 1:3714 EAGLE DR NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-2710
Mailing Address - Country:US
Mailing Address - Phone:509-438-6899
Mailing Address - Fax:
Practice Address - Street 1:12515 MERIDIAN E
Practice Address - Street 2:SUITE 201
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3436
Practice Address - Country:US
Practice Address - Phone:253-841-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-03
Last Update Date:2016-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60625268225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist