Provider Demographics
NPI:1518583111
Name:NIKODYM, LISA SUE (MT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SUE
Last Name:NIKODYM
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N BENTON DRIVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-1597
Mailing Address - Country:US
Mailing Address - Phone:320-252-2225
Mailing Address - Fax:320-252-2159
Practice Address - Street 1:225 N BENTON DRIVE
Practice Address - Street 2:SUITE 105
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-1597
Practice Address - Country:US
Practice Address - Phone:320-252-2225
Practice Address - Fax:320-252-2159
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist