Provider Demographics
NPI:1639483761
Name:CAMPOS, CARISSA RUTH (LMT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:RUTH
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 1:14783 SW 109TH AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3224
Mailing Address - Country:US
Mailing Address - Phone:503-487-7348
Mailing Address - Fax:
Practice Address - Street 1:14783 SW 109TH AVE
Practice Address - Street 2:APT 1
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3224
Practice Address - Country:US
Practice Address - Phone:503-487-7348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13603225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist