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General NPI Number Information
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NPI Number | 1730699976
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Entity Type | Individual
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Provider Name | LISA D BLAKE LMT
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Gender | Female
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Dates
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Enumeration Date | 10/02/2017
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Last Update Date | 10/02/2017
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Provider Practice Location Address
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Address Line | 2705 E BURNSIDE ST STE 213
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City | PORTLAND
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State | OR
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Zip | 97214-1768
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Country | US
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Telephone | 503-234-4288
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Fax |
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Provider Business Mailing Address
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Address Line | 5319 SE 69TH AVE
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City | PORTLAND
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State | OR
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Zip | 97206-5343
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Country | US
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Telephone | 603-219-1318
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 18230
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License Number State | OR
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