Provider Demographics
NPI:1417324807
Name:KISOR, LAURI (LPTA, LMT)
Entity Type:Individual
Prefix:MRS
First Name:LAURI
Middle Name:
Last Name:KISOR
Suffix:
Gender:F
Credentials:LPTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 SW 34TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-8072
Mailing Address - Country:US
Mailing Address - Phone:541-579-0164
Mailing Address - Fax:
Practice Address - Street 1:2213 SW 34TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-8072
Practice Address - Country:US
Practice Address - Phone:541-579-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21331225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist