Provider Demographics
NPI:1639642457
Name:DEGROOT, MARY A (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:DEGROOT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:360 71ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-7219
Mailing Address - Country:US
Mailing Address - Phone:541-914-5279
Mailing Address - Fax:
Practice Address - Street 1:1200 HIGH ST STE 110
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3232
Practice Address - Country:US
Practice Address - Phone:541-914-5279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23747225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty