Provider Demographics
NPI:1861639676
Name:BRADY, LISA M (LAC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:BRADY
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 1:5124 NE MASON CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2138
Mailing Address - Country:US
Mailing Address - Phone:503-336-1205
Mailing Address - Fax:
Practice Address - Street 1:4515 NE FREMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1175
Practice Address - Country:US
Practice Address - Phone:503-281-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR027722171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist