Provider Demographics
NPI:1730699976
Name:BLAKE, LISA D (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:BLAKE
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 1:5319 SE 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-5343
Mailing Address - Country:US
Mailing Address - Phone:603-219-1318
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST STE 213
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1768
Practice Address - Country:US
Practice Address - Phone:503-234-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18230225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist