Provider Demographics
NPI:1629211545
Name:BETSWORTH, PAMELA LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:LYNN
Last Name:BETSWORTH
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 2332
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0206
Mailing Address - Country:US
Mailing Address - Phone:541-660-1648
Mailing Address - Fax:
Practice Address - Street 1:790 NE WHARTON DR
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1631
Practice Address - Country:US
Practice Address - Phone:541-660-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11631225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist