Provider Demographics
NPI:1124834429
Name:BURBRIDGE, TITUS WILLIAM (LMT)
Entity type:Individual
Prefix:
First Name:TITUS
Middle Name:WILLIAM
Last Name:BURBRIDGE
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 1:82611 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-6052
Mailing Address - Country:US
Mailing Address - Phone:503-960-5611
Mailing Address - Fax:
Practice Address - Street 1:82611 MAPLE RD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-6052
Practice Address - Country:US
Practice Address - Phone:503-960-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22822225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist