Provider Demographics
NPI:1649791534
Name:LAZO, CORINNE CRISTINA
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:CRISTINA
Last Name:LAZO
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 1:6823 SE CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6514
Mailing Address - Country:US
Mailing Address - Phone:503-869-7470
Mailing Address - Fax:
Practice Address - Street 1:15110 BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3468
Practice Address - Country:US
Practice Address - Phone:503-869-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14696225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist