Provider Demographics
NPI:1255664660
Name:PETERS, LISA FERN (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:FERN
Last Name:PETERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:FERN
Other - Last Name:ILES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:156 SE 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4161
Mailing Address - Country:US
Mailing Address - Phone:503-681-8125
Mailing Address - Fax:503-681-8739
Practice Address - Street 1:156 SE 4TH AVE.
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4161
Practice Address - Country:US
Practice Address - Phone:503-681-8125
Practice Address - Fax:503-681-8739
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13414225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist