Provider Demographics
NPI:1558628008
Name:CAMPOS, LISA MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 NW 173RD AVE
Mailing Address - Street 2:APT #1610
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006
Mailing Address - Country:US
Mailing Address - Phone:503-997-0680
Mailing Address - Fax:
Practice Address - Street 1:1925 NW 173RD AVE
Practice Address - Street 2:APT #1610
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7319
Practice Address - Country:US
Practice Address - Phone:503-997-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18388174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist