Provider Demographics
NPI:1376184119
Name:WYRICK, EMILIE (LMT)
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:
Last Name:WYRICK
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 1:1916 NE 125TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1807
Mailing Address - Country:US
Mailing Address - Phone:707-738-7351
Mailing Address - Fax:
Practice Address - Street 1:2188 SW PARK PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1100
Practice Address - Country:US
Practice Address - Phone:707-738-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist