Provider Demographics
NPI:1508334194
Name:TETZ, BRIAN (LMT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:TETZ
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 1:23751 SW ELDERBERRY LN
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-9111
Mailing Address - Country:US
Mailing Address - Phone:719-393-3574
Mailing Address - Fax:
Practice Address - Street 1:23751 SW ELDERBERRY LN
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-9111
Practice Address - Country:US
Practice Address - Phone:719-393-3574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24319225700000X
ORAC191454171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist