Provider Demographics
NPI:1497087555
Name:NORMAN, WANDA ELIZABETH (LMT, LAC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:ELIZABETH
Last Name:NORMAN
Suffix:
Gender:F
Credentials:LMT, LAC
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:ELIZABETH
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10915 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3348
Mailing Address - Country:US
Mailing Address - Phone:503-261-1120
Mailing Address - Fax:503-261-8936
Practice Address - Street 1:10915 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3348
Practice Address - Country:US
Practice Address - Phone:503-261-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-31
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150417171100000X
OR12447225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR12447OtherMASSAGE LICENSE
ORAC150417OtherACUPUNCTURE LICENSE