Healthcare Provider Details

I. General information

NPI: 1497482277
Provider Name (Legal Business Name): ALISSA CHRISTINE CISCO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3835 SW 185TH AVE
BEAVERTON OR
97078-1502
US

IV. Provider business mailing address

1022 SE BACARRA ST
HILLSBORO OR
97123-4694
US

V. Phone/Fax

Practice location:
  • Phone: 503-626-2166
  • Fax: 503-641-6665
Mailing address:
  • Phone: 702-374-3096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27184
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: