Provider Demographics
NPI:1851585608
Name:WAGNER, KARIN E (CERTIFIED ROLFER LMT)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CERTIFIED ROLFER LMT
Other - Prefix:
Other - First Name:KARIN
Other - Middle Name:N
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CERTIFIED ROLFER LMT
Mailing Address - Street 1:2732 SE 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2265
Mailing Address - Country:US
Mailing Address - Phone:503-230-0087
Mailing Address - Fax:
Practice Address - Street 1:2732 SE 18TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2265
Practice Address - Country:US
Practice Address - Phone:503-230-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11497225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist