Provider Demographics
NPI:1205470580
Name:LOVELL, TERA MARIE (MOTR/L)
Entity type:Individual
Prefix:MISS
First Name:TERA
Middle Name:MARIE
Last Name:LOVELL
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 JORDAN RD
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9672
Mailing Address - Country:US
Mailing Address - Phone:360-880-7026
Mailing Address - Fax:
Practice Address - Street 1:2519 COVE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3910
Practice Address - Country:US
Practice Address - Phone:541-962-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60282840225X00000X
AK123152225X00000X
OR225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist