Provider Demographics
NPI:1629368196
Name:BARKER, ALEXIS MIRANDA (LAC)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MIRANDA
Last Name:BARKER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2073
Mailing Address - Country:US
Mailing Address - Phone:503-758-9760
Mailing Address - Fax:
Practice Address - Street 1:4929 NE 30TH AVE
Practice Address - Street 2:ZEN SPACE HEALING
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211
Practice Address - Country:US
Practice Address - Phone:503-281-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2021-02-08
Deactivation Date:2020-12-08
Deactivation Code:
Reactivation Date:2021-02-03
Provider Licenses
StateLicense IDTaxonomies
OR17304225700000X
ORAC202639171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist