Provider Demographics
NPI:1891933289
Name:BOURLON, LISA ANN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BOURLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13345 SW BRIGHTWOOD STREET
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1222
Mailing Address - Country:US
Mailing Address - Phone:503-358-3385
Mailing Address - Fax:
Practice Address - Street 1:238 SE 2 AVENUE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97123
Practice Address - Country:US
Practice Address - Phone:503-358-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14779225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist