Provider Demographics
NPI:1952695959
Name:RETZLAFF, MARK MASON (LMT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MASON
Last Name:RETZLAFF
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 1:11912 SE SCHILLER ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3269
Mailing Address - Country:US
Mailing Address - Phone:541-221-3084
Mailing Address - Fax:
Practice Address - Street 1:11220 SE STARK ST STE 6
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3384
Practice Address - Country:US
Practice Address - Phone:541-221-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18181225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist