Provider Demographics
NPI:1841403466
Name:RIVOLI, MISTY LYNN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:LYNN
Last Name:RIVOLI
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 1:1620 NE GOING ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-5054
Mailing Address - Country:US
Mailing Address - Phone:503-318-4870
Mailing Address - Fax:503-284-8781
Practice Address - Street 1:6124 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5347
Practice Address - Country:US
Practice Address - Phone:503-318-4870
Practice Address - Fax:503-284-8781
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5898174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist