Provider Demographics
NPI:1942956222
Name:SHULTZ, LISA ANN (DSOM, LAC, LMT)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:SHULTZ
Suffix:
Gender:F
Credentials:DSOM, LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12860 SW GLENHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-4734
Mailing Address - Country:US
Mailing Address - Phone:503-643-6944
Mailing Address - Fax:
Practice Address - Street 1:1110 SE ALDER ST STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2400
Practice Address - Country:US
Practice Address - Phone:503-477-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24554225700000X
ORAC208926171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist