Provider Demographics
NPI:1568854016
Name:NOONAN, LARISA (LMT)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:NOONAN
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 1:597 W VISTA AVE S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5573
Mailing Address - Country:US
Mailing Address - Phone:503-975-3300
Mailing Address - Fax:
Practice Address - Street 1:3804 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4330
Practice Address - Country:US
Practice Address - Phone:503-975-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9384172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist