Provider Demographics
NPI:1063790368
Name:WILLSON, LUISE (CMT, NCMT, LMT)
Entity type:Individual
Prefix:MS
First Name:LUISE
Middle Name:
Last Name:WILLSON
Suffix:
Gender:F
Credentials:CMT, NCMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10332 NE OREGON ST
Mailing Address - Street 2:#12
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220
Mailing Address - Country:US
Mailing Address - Phone:720-877-6926
Mailing Address - Fax:
Practice Address - Street 1:10332 NE OREGON ST
Practice Address - Street 2:#12
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:720-877-6926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1362225700000X
OR18322225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist