Provider Demographics
NPI:1467226381
Name:FAUST, MCKENZIE FREYDIS (LMT# 27933)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:FREYDIS
Last Name:FAUST
Suffix:
Gender:F
Credentials:LMT# 27933
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:MCKENZIE
Other - Last Name:FOUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10151 SW BARBUR BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5951
Mailing Address - Country:US
Mailing Address - Phone:971-280-9707
Mailing Address - Fax:
Practice Address - Street 1:10151 SW BARBUR BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5951
Practice Address - Country:US
Practice Address - Phone:971-280-9707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist