Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 012286-1 | NY |
NPI | 1013034305 |
---|---|
Provider Name | Lisa Anne Main |
First Address | Leroy, NY 14482 |
Second Address | Leroy, NY 14482 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2007 |
Last Update Date | 08/07/2007 |