Provider Demographics
NPI:1700112448
Name:STUBAN, LISA (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:STUBAN
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2688 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2503
Mailing Address - Country:US
Mailing Address - Phone:208-244-5658
Mailing Address - Fax:
Practice Address - Street 1:2688 HILLVIEW DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2503
Practice Address - Country:US
Practice Address - Phone:208-244-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-31
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDBL7614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist