Provider Demographics
NPI:1699039115
Name:SORENSEN, LISA MK (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MK
Last Name:SORENSEN
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 1:17010 SE STARK ST
Mailing Address - Street 2:APT. D311
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-6205
Mailing Address - Country:US
Mailing Address - Phone:503-262-0907
Mailing Address - Fax:
Practice Address - Street 1:16742 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1414
Practice Address - Country:US
Practice Address - Phone:503-761-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist