Provider Demographics
NPI:1700264934
Name:WORLOCK, MATT (LMT)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:WORLOCK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2572 NW VAUGHN ST
Mailing Address - Street 2:APT D.
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2555
Mailing Address - Country:US
Mailing Address - Phone:971-570-5870
Mailing Address - Fax:
Practice Address - Street 1:2572 NW VAUGHN ST
Practice Address - Street 2:APT D.
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2555
Practice Address - Country:US
Practice Address - Phone:971-570-5870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21346225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist