Provider Demographics
NPI:1073886487
Name:CECIL, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CECIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 36TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4741
Mailing Address - Country:US
Mailing Address - Phone:503-371-8860
Mailing Address - Fax:
Practice Address - Street 1:685 36TH AVE NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4741
Practice Address - Country:US
Practice Address - Phone:503-371-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-15
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005996225100000X
IN05010733A2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist