Provider Demographics
NPI:1629745898
Name:HARRISON, PENNY (LMT)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:HARRISON
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 1:8550 SW APPLE WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-1772
Mailing Address - Country:US
Mailing Address - Phone:503-523-7836
Mailing Address - Fax:503-894-9699
Practice Address - Street 1:8550 SW APPLE WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-1772
Practice Address - Country:US
Practice Address - Phone:503-523-7836
Practice Address - Fax:503-894-9699
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2983225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR139615944Medicaid