Provider Demographics
NPI:1063838720
Name:BLACK, ANDREW ALLEN (LMT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:ALLEN
Last Name:BLACK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6145 SW SHANNON CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-4668
Mailing Address - Country:US
Mailing Address - Phone:503-598-8099
Mailing Address - Fax:503-598-3980
Practice Address - Street 1:14511 WESTLAKE DR STE 100
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7727
Practice Address - Country:US
Practice Address - Phone:503-598-8099
Practice Address - Fax:503-598-3980
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19070225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist