Provider Demographics
NPI:1295007466
Name:LILJENBERG, ALAN ROBERT (LMT)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:ROBERT
Last Name:LILJENBERG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 PIONEER CIR
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-3312
Mailing Address - Country:US
Mailing Address - Phone:503-707-5379
Mailing Address - Fax:
Practice Address - Street 1:1911 MOUNTAIN VIEW LN STE 400
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2248
Practice Address - Country:US
Practice Address - Phone:503-707-5379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14709225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist