Provider Demographics
NPI:1649477597
Name:PAMPO, MARY GRACE (LAC, CYI, CMT)
Entity type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:
Last Name:PAMPO
Suffix:
Gender:F
Credentials:LAC, CYI, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 NE CORNELL RD
Mailing Address - Street 2:250
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5412
Mailing Address - Country:US
Mailing Address - Phone:503-747-2259
Mailing Address - Fax:
Practice Address - Street 1:6125 NE CORNELL RD
Practice Address - Street 2:250
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5412
Practice Address - Country:US
Practice Address - Phone:503-747-2259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01055171100000X
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist