Provider Demographics
NPI:1255605523
Name:MASSENGALE, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:MASSENGALE
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 1:205 E MAIN ST
Mailing Address - Street 2:SUITE 11
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4057
Mailing Address - Country:US
Mailing Address - Phone:503-536-5146
Mailing Address - Fax:503-846-9100
Practice Address - Street 1:205 E MAIN ST
Practice Address - Street 2:SUITE 11
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4057
Practice Address - Country:US
Practice Address - Phone:503-536-5146
Practice Address - Fax:503-846-9100
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13533172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist