Provider Demographics
NPI:1083903363
Name:IACOVELLI, DAMON E (LMT)
Entity Type:Individual
Prefix:MR
First Name:DAMON
Middle Name:E
Last Name:IACOVELLI
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 1:4309 SE TIBBETTS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3124
Mailing Address - Country:US
Mailing Address - Phone:503-380-1021
Mailing Address - Fax:
Practice Address - Street 1:270 NE 181ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6663
Practice Address - Country:US
Practice Address - Phone:503-669-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17153225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist