MEDICARE: LISA MARY PORTER OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	995621	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477512531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARY PORTER OT

Provider Business Mailing Address
First Line	:	5232 N INTERSTATE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-3767
Country	:	US
Telephone Number	:	503-575-9402
Fax Number	:

Provider Business Practice Location Address
First Line	:	5232 N INTERSTATE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-4023
Country	:	US
Telephone Number	:	503-449-0788
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2006
Last Update Date	:	08/26/2011

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