1730467705 NPI number — MRS. LORI VALENTINE WILSON P.T.

Table of content: MRS. LORI VALENTINE WILSON P.T. (NPI 1730467705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730467705 NPI number — MRS. LORI VALENTINE WILSON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
LORI
Provider Middle Name:
VALENTINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
LORI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1730467705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-366-2983
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 PACIFIC AVE
Provider Second Line Business Practice Location Address:
FIRST FLOOR
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-4168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-258-7311
Provider Business Practice Location Address Fax Number:
425-258-7618
Provider Enumeration Date:
07/25/2011

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: 2251P0200X , with the licence number:  PT00007929 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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