Provider Demographics
NPI:1255540845
Name:MERTZ, LISA RENEE (LMT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENEE
Last Name:MERTZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1720
Mailing Address - Country:US
Mailing Address - Phone:503-473-9339
Mailing Address - Fax:503-281-0278
Practice Address - Street 1:2627 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1720
Practice Address - Country:US
Practice Address - Phone:503-473-9339
Practice Address - Fax:503-281-0278
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12050174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist