Provider Demographics
NPI:1720138795
Name:ANDERSEN, TRACY (DAOM, LAC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 NW THURMAN ST
Mailing Address - Street 2:SUITE O
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2581
Mailing Address - Country:US
Mailing Address - Phone:503-250-3012
Mailing Address - Fax:503-208-8028
Practice Address - Street 1:2301 NW THURMAN ST
Practice Address - Street 2:SUITE O
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2581
Practice Address - Country:US
Practice Address - Phone:503-250-3012
Practice Address - Fax:503-208-8028
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00816171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist