Provider Demographics
NPI:1104118926
Name:VISCONTY, CRISTEN ELISSA (LMT, CVT)
Entity type:Individual
Prefix:
First Name:CRISTEN
Middle Name:ELISSA
Last Name:VISCONTY
Suffix:
Gender:F
Credentials:LMT, CVT
Other - Prefix:
Other - First Name:LISSA
Other - Middle Name:
Other - Last Name:VISCONTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT, CVT
Mailing Address - Street 1:PO BOX 255
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-0255
Mailing Address - Country:US
Mailing Address - Phone:971-404-4092
Mailing Address - Fax:
Practice Address - Street 1:17150 UNIVERSITY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-9290
Practice Address - Country:US
Practice Address - Phone:503-668-6524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17417174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist