Provider Demographics
NPI:1053646307
Name:MATHRE, CAROL R (LMT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:R
Last Name:MATHRE
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 1:41991 MEYER LN
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-8428
Mailing Address - Country:US
Mailing Address - Phone:503-440-3664
Mailing Address - Fax:
Practice Address - Street 1:1154 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4126
Practice Address - Country:US
Practice Address - Phone:503-440-3664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11681225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist