Provider Demographics
NPI:1376271833
Name:HEAD, ROBERT EARL (LMT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EARL
Last Name:HEAD
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 1:3939 NE HANCOCK ST STE 303
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5321
Mailing Address - Country:US
Mailing Address - Phone:971-645-6347
Mailing Address - Fax:
Practice Address - Street 1:3939 NE HANCOCK ST STE 303
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5321
Practice Address - Country:US
Practice Address - Phone:971-645-6347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR26538OtherOREGON BOARD OF MASSAGE THERAPY