Individual
MRS. LISA DENISE BROADOUS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2330 NE SISKIYOU ST, PORTLAND, OR 97212-2471
(503) 528-0757
Mailing address
6903 N ALBINA AVE, PORTLAND, OR 97217-1603
(503) 415-1892
Taxonomy
Speciality
Code
Description
License number
State
372600000X
Adult Companion
Primary
—
—
Other
Enumeration date
04/11/2007
Last updated
07/08/2007
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