Provider Demographics
NPI:1093013211
Name:SMITH, AARISA ELYSIANNE (LMT)
Entity Type:Individual
Prefix:
First Name:AARISA
Middle Name:ELYSIANNE
Last Name:SMITH
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 1:4306 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-5356
Mailing Address - Country:US
Mailing Address - Phone:760-613-5022
Mailing Address - Fax:
Practice Address - Street 1:443 NE KNOTT ST # 6
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3108
Practice Address - Country:US
Practice Address - Phone:760-613-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60043874172M00000X
ORLMT 15732172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist