Provider Demographics
NPI:1639407265
Name:MATTHEWS, LORI (NCTMB)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2479 COUNTY ROAD E E
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4807
Mailing Address - Country:US
Mailing Address - Phone:612-270-5760
Mailing Address - Fax:
Practice Address - Street 1:2479 COUNTY ROAD E E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-4807
Practice Address - Country:US
Practice Address - Phone:612-270-5760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT450533-07225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist