Provider Demographics
NPI:1851716260
Name:VICENTE, LORELIE
Entity Type:Individual
Prefix:
First Name:LORELIE
Middle Name:
Last Name:VICENTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 MARKET ST NE
Mailing Address - Street 2:PMB 485
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1826
Mailing Address - Country:US
Mailing Address - Phone:541-361-0335
Mailing Address - Fax:
Practice Address - Street 1:3760 MARKET ST NE
Practice Address - Street 2:PMB 485
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1826
Practice Address - Country:US
Practice Address - Phone:541-361-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3570484OtherDRIVER'S LICENSE