Provider Demographics
NPI:1588713549
Name:WOLFF, LISA MARCHELL GOULD (MOT, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARCHELL GOULD
Last Name:WOLFF
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARCHELL
Other - Last Name:GOULD-YORK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:12650 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1058
Mailing Address - Country:US
Mailing Address - Phone:503-477-9527
Mailing Address - Fax:503-477-9529
Practice Address - Street 1:12650 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-477-9527
Practice Address - Fax:503-477-9527
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1076095225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7684103Medicaid
OR273905Medicaid
WA7684103Medicaid