Provider Demographics
NPI:1982246849
Name:SECREST, KARIN I (LMT #7488)
Entity Type:Individual
Prefix:MRS
First Name:KARIN
Middle Name:I
Last Name:SECREST
Suffix:
Gender:F
Credentials:LMT #7488
Other - Prefix:
Other - First Name:KARIN
Other - Middle Name:I
Other - Last Name:WENGEROWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1762 W 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-1663
Mailing Address - Country:US
Mailing Address - Phone:541-870-8762
Mailing Address - Fax:
Practice Address - Street 1:656 CHARNELTON ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2689
Practice Address - Country:US
Practice Address - Phone:541-653-8692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR9727373OtherDRIVERS LICENSE