Provider Demographics
NPI:1063821528
Name:MASCOLA, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MASCOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3519 NE 15TH AVE STE 580
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2356
Mailing Address - Country:US
Mailing Address - Phone:603-686-1219
Mailing Address - Fax:
Practice Address - Street 1:3519 NE 15TH AVE STE 580
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2356
Practice Address - Country:US
Practice Address - Phone:503-882-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13630225X00000X, 225XP0200X
OR275463225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist