Provider Demographics
NPI:1104037035
Name:PONTIUS, VALERIE RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:RENEE
Last Name:PONTIUS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8488 SW MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9135
Mailing Address - Country:US
Mailing Address - Phone:503-318-1129
Mailing Address - Fax:
Practice Address - Street 1:23000 SW PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8061
Practice Address - Country:US
Practice Address - Phone:503-318-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2011-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021696171W00000X
OR10329171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA912075994-09OtherKPS HEALTH PLANS
WA0209123OtherLABOR & INDUSTRIES