Provider Demographics
NPI:1285690396
Name:MCCLISH, JOANNA L (ATC, LMT)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:L
Last Name:MCCLISH
Suffix:
Gender:F
Credentials:ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 NE 42ND AVE
Mailing Address - Street 2:#209
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1399
Mailing Address - Country:US
Mailing Address - Phone:503-309-1333
Mailing Address - Fax:
Practice Address - Street 1:5112 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2940
Practice Address - Country:US
Practice Address - Phone:503-309-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11778225700000X
ORAT-AT-101412692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer