Provider Demographics
NPI:1457171332
Name:WAHLBERG, ZARAH (LMT)
Entity type:Individual
Prefix:
First Name:ZARAH
Middle Name:
Last Name:WAHLBERG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 NW SAGINAW AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1652
Mailing Address - Country:US
Mailing Address - Phone:503-679-8035
Mailing Address - Fax:
Practice Address - Street 1:1010 NW HARRIMAN ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1912
Practice Address - Country:US
Practice Address - Phone:541-241-6021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT-20644225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist