Provider Demographics
NPI:1609073147
Name:DICK, BRENDA S (LMT)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:S
Last Name:DICK
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:PO BOX 21689
Mailing Address - Street 2:4705 RIVER ROAD N
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-1689
Mailing Address - Country:US
Mailing Address - Phone:503-393-4121
Mailing Address - Fax:503-393-3191
Practice Address - Street 1:4705 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4535
Practice Address - Country:US
Practice Address - Phone:503-393-4121
Practice Address - Fax:503-393-3191
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist