Provider Demographics
NPI:1790164895
Name:WILSON, TAMMIE LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TAMMIE
Other - Middle Name:LYNN
Other - Last Name:BITTICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7180 SW FIR LOOP STE 250
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8077
Mailing Address - Country:US
Mailing Address - Phone:033-417-1815
Mailing Address - Fax:
Practice Address - Street 1:7180 SW FIR LOOP STE 250
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8077
Practice Address - Country:US
Practice Address - Phone:503-341-7181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20919225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist