Provider Demographics
NPI:1497023402
Name:FROST, HAZEL (LMT)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:FROST
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 1:2822 NE RODNEY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3024
Mailing Address - Country:US
Mailing Address - Phone:503-422-3073
Mailing Address - Fax:
Practice Address - Street 1:2225 NE ALBERTA ST
Practice Address - Street 2:SUITE 5
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-5886
Practice Address - Country:US
Practice Address - Phone:503-422-3073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18612225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist