Provider Demographics
NPI:1902042773
Name:ELLIS, LISA MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:ELLIS
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 1:1212 SE POWELL BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2460
Mailing Address - Country:US
Mailing Address - Phone:541-556-3443
Mailing Address - Fax:954-963-7169
Practice Address - Street 1:1212 SE POWELL BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2460
Practice Address - Country:US
Practice Address - Phone:541-556-3443
Practice Address - Fax:954-963-7169
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00600171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist