1336435486 NPI number — MARISSA M LOOSLI DPT

Table of content: MARISSA M LOOSLI DPT (NPI 1336435486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336435486 NPI number — MARISSA M LOOSLI DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOOSLI
Provider First Name:
MARISSA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336435486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4950 NE BELKNAP CT
Provider Second Line Business Mailing Address:
STE 107
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97124-5114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-835-5349
Provider Business Mailing Address Fax Number:
360-835-5390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 222
Provider Business Practice Location Address City Name:
WASHOUGAL
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98671-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-835-5349
Provider Business Practice Location Address Fax Number:
360-835-5390
Provider Enumeration Date:
06/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  06574 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 60218867 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com