Provider Demographics
NPI:1083175228
Name:HARMAN, MALLORY A (LAC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:HARMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 S WHITAKER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4810
Mailing Address - Country:US
Mailing Address - Phone:406-690-2003
Mailing Address - Fax:
Practice Address - Street 1:4233 S CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4203
Practice Address - Country:US
Practice Address - Phone:503-482-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-ACU-LIC-74129171100000X
ORAC189993171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500767031Medicaid