Healthcare Provider Details

I. General information

NPI: 1649188335
Provider Name (Legal Business Name): LISA NORDSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N DIXON ST
PORTLAND OR
97227-1876
US

IV. Provider business mailing address

501 N DIXON ST
PORTLAND OR
97227-1876
US

V. Phone/Fax

Practice location:
  • Phone: 907-288-9081
  • Fax:
Mailing address:
  • Phone: 971-288-9081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number145077
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: