Provider Demographics
NPI:1861736829
Name:FRIES, LISA RAE (LMT)
Entity type:Individual
Prefix:MISS
First Name:LISA
Middle Name:RAE
Last Name:FRIES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 BEECHER XING N
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-4564
Mailing Address - Country:US
Mailing Address - Phone:614-855-8828
Mailing Address - Fax:
Practice Address - Street 1:1110 BEECHER XING N
Practice Address - Street 2:SUITE B
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-4564
Practice Address - Country:US
Practice Address - Phone:614-855-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.017114-E-G225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist