Provider Demographics
NPI:1760727630
Name:HALTER, MARY E (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:HALTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:LEMONTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4560 SE INDUSTRIAL WAY
Mailing Address - Street 2:STE. 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5200
Mailing Address - Fax:971-206-5203
Practice Address - Street 1:2051 POTTERY AVE.
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-876-4461
Practice Address - Fax:360-876-4482
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160280598225200000X
COPTA.0013800225200000X
VA2306604047225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant