Provider Demographics
NPI:1609304476
Name:WICKLUND, LISA MARIE (LMT)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:WICKLUND
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 1:9140 BALTIMORE ST NE STE 140-5
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4382
Mailing Address - Country:US
Mailing Address - Phone:612-481-9718
Mailing Address - Fax:
Practice Address - Street 1:9140 BALTIMORE ST NE STE 140-5
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4382
Practice Address - Country:US
Practice Address - Phone:612-481-9718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17-07455225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist