Provider Demographics
NPI:1740442300
Name:AVGI, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AVGI
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 1:13059 BETHLEHEM DR NE
Mailing Address - Street 2:
Mailing Address - City:GERVAIS
Mailing Address - State:OR
Mailing Address - Zip Code:97026-8784
Mailing Address - Country:US
Mailing Address - Phone:503-569-3995
Mailing Address - Fax:
Practice Address - Street 1:13059 BETHLEHEM DR NE
Practice Address - Street 2:
Practice Address - City:GERVAIS
Practice Address - State:OR
Practice Address - Zip Code:97026
Practice Address - Country:US
Practice Address - Phone:503-569-3995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10327171W00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171W00000XOther Service ProvidersContractor