Provider Demographics
NPI:1710282876
Name:CONNER, CARISSA CAMILE (LMT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:CAMILE
Last Name:CONNER
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 1:1427 A NW FLANDERS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209
Mailing Address - Country:US
Mailing Address - Phone:503-972-0235
Mailing Address - Fax:503-379-1523
Practice Address - Street 1:1427 NW FLANDERS SUITE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209
Practice Address - Country:US
Practice Address - Phone:503-972-0235
Practice Address - Fax:503-379-1523
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7285225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist