Provider Demographics
NPI:1548686876
Name:LONGORIA, LISA MARIE I
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:LONGORIA
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:17165 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:MI
Mailing Address - Zip Code:49303-9729
Mailing Address - Country:US
Mailing Address - Phone:616-914-7362
Mailing Address - Fax:231-282-7057
Practice Address - Street 1:17615 BAILEY RD
Practice Address - Street 2:
Practice Address - City:BAILEY
Practice Address - State:MI
Practice Address - Zip Code:49303-9729
Practice Address - Country:US
Practice Address - Phone:616-914-7362
Practice Address - Fax:231-282-7057
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002188225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist