Provider Demographics
NPI:1114215373
Name:SHEPARD-GLENN, LAURIE (LMT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:SHEPARD-GLENN
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 1:0110 SW BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4062
Mailing Address - Country:US
Mailing Address - Phone:503-358-4383
Mailing Address - Fax:
Practice Address - Street 1:0110 SW BANCROFT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4062
Practice Address - Country:US
Practice Address - Phone:503-358-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6093225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist