Provider Demographics
NPI:1285169292
Name:BRADY, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 KELLY ST NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-2062
Mailing Address - Country:US
Mailing Address - Phone:503-930-8345
Mailing Address - Fax:
Practice Address - Street 1:182 SW ACADEMY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1996
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)