Provider Demographics
NPI:1497936629
Name:TEAGUE, LISA (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BOAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2083 NW JOHNSON ST. #34
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209
Mailing Address - Country:US
Mailing Address - Phone:503-329-3577
Mailing Address - Fax:
Practice Address - Street 1:511 SW 10TH AVE STE 1109
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2712
Practice Address - Country:US
Practice Address - Phone:503-329-3577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist