Healthcare Provider Details

I. General information

NPI: 1609044643
Provider Name (Legal Business Name): LAURA LIVESAY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 E BURNSIDE ST STE 218
PORTLAND OR
97214-1231
US

IV. Provider business mailing address

811 E BURNSIDE ST STE 218
PORTLAND OR
97214-1231
US

V. Phone/Fax

Practice location:
  • Phone: 503-844-0842
  • Fax: 503-547-8894
Mailing address:
  • Phone: 503-844-0842
  • Fax: 503-547-8894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8076
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: