Provider Demographics
NPI:1942818216
Name:SHOSTAK, LISA DARYA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DARYA
Last Name:SHOSTAK
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 1:7800 SW BARBUR BLVD BLDG 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2823
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:
Practice Address - Street 1:7800 SW BARBUR BLVD BLDG 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2823
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician