Provider Demographics
NPI:1649746116
Name:NORBOM, AMY JO (LMBT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:NORBOM
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4501
Mailing Address - Country:US
Mailing Address - Phone:360-317-8684
Mailing Address - Fax:
Practice Address - Street 1:906 W 15TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3533
Practice Address - Country:US
Practice Address - Phone:360-317-8684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16639225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist