Provider Demographics
NPI:1225635287
Name:VESELY, LISA LYNN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:VESELY
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 1:1335 NW 23RD AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2687
Mailing Address - Country:US
Mailing Address - Phone:503-960-1025
Mailing Address - Fax:
Practice Address - Street 1:1122 NE 122ND AVE STE A200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2083
Practice Address - Country:US
Practice Address - Phone:503-594-4750
Practice Address - Fax:971-888-4607
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT20163101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)