Provider Demographics
NPI:1629102454
Name:DIMICK, LOIS ELIZABETH YEVDALCIA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LOIS ELIZABETH
Middle Name:YEVDALCIA
Last Name:DIMICK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:LOIS ELIZABETH
Other - Middle Name:YEVDALCIA
Other - Last Name:CAMARILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1912 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116
Mailing Address - Country:US
Mailing Address - Phone:503-380-7753
Mailing Address - Fax:503-359-4760
Practice Address - Street 1:2004 MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116
Practice Address - Country:US
Practice Address - Phone:503-380-7753
Practice Address - Fax:503-359-4760
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11715225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist