Provider Demographics
NPI:1104049246
Name:ERVIN, MYLISA ANNE (LMT)
Entity type:Individual
Prefix:MRS
First Name:MYLISA
Middle Name:ANNE
Last Name:ERVIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 ADAMS LOOP
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-9743
Mailing Address - Country:US
Mailing Address - Phone:503-319-4785
Mailing Address - Fax:
Practice Address - Street 1:836 ADAMS LOOP
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-9743
Practice Address - Country:US
Practice Address - Phone:503-319-4785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7101172M00000X
WAMA00013019172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist