Provider Demographics
NPI:1073753372
Name:HARRIS, TOMMY LEE (LMT)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:LEE
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38954 PROCTOR BLVD # 397
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-8039
Mailing Address - Country:US
Mailing Address - Phone:503-804-4621
Mailing Address - Fax:503-665-3188
Practice Address - Street 1:735 SE MOUNT HOOD HWY
Practice Address - Street 2:SUITE C
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-9280
Practice Address - Country:US
Practice Address - Phone:503-804-4621
Practice Address - Fax:503-665-3188
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10077225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist