Provider Demographics
NPI:1003708173
Name:WILLIAMS, LISA MARIE (CMT, MLD-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CMT, MLD-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 DRESDEN ALCOVE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:MN
Mailing Address - Zip Code:55390-5421
Mailing Address - Country:US
Mailing Address - Phone:763-691-3430
Mailing Address - Fax:
Practice Address - Street 1:9175 QUADAY AVE NE STE 106
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-6660
Practice Address - Country:US
Practice Address - Phone:763-691-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21706206225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty