Provider Demographics
NPI:1477512531
Name:PORTER, LISA MARY (OT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARY
Last Name:PORTER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5232 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3767
Mailing Address - Country:US
Mailing Address - Phone:503-575-9402
Mailing Address - Fax:
Practice Address - Street 1:5232 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4023
Practice Address - Country:US
Practice Address - Phone:503-449-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR995621225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231888Medicaid
OR386526Medicare ID - Type Unspecified