Provider Demographics
NPI:1184037905
Name:PENDLETON, LISA (LMT)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:HULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:15143 SW KENTON DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7374
Mailing Address - Country:US
Mailing Address - Phone:503-201-7444
Mailing Address - Fax:
Practice Address - Street 1:18813 SW MARTINAZZI AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6807
Practice Address - Country:US
Practice Address - Phone:503-765-5265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11127225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist