Provider Demographics
NPI:1083809313
Name:HARTL, LISA A
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:HARTL
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 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:888-757-3422
Mailing Address - Fax:
Practice Address - Street 1:3457 NE DIVISION ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-4602
Practice Address - Country:US
Practice Address - Phone:503-667-1965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8373225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant