Provider Demographics
NPI:1386184422
Name:LASICH, AIMEE MAUCK
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:MAUCK
Last Name:LASICH
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 1:1450 N PRESCOTT ST
Mailing Address - Street 2:APT 411
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3202
Mailing Address - Country:US
Mailing Address - Phone:503-780-7195
Mailing Address - Fax:503-288-8972
Practice Address - Street 1:1450 N PRESCOTT ST
Practice Address - Street 2:APT 411
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3202
Practice Address - Country:US
Practice Address - Phone:503-780-7195
Practice Address - Fax:503-288-8972
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14598225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist