Provider Demographics
NPI:1376683045
Name:LEWIS, SAMANTHA BANGONE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:BANGONE
Last Name:LEWIS
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 1:13185 SW BUTNER CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-0833
Mailing Address - Country:US
Mailing Address - Phone:503-806-4652
Mailing Address - Fax:
Practice Address - Street 1:13185 SW BUTNER CT
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0833
Practice Address - Country:US
Practice Address - Phone:503-806-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12490225700000X
WAMA00021799225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist