Provider Demographics
NPI:1124839584
Name:WRIGHT, JOHANNA ROBIN (LMT)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:ROBIN
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 NE FARGO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2025
Mailing Address - Country:US
Mailing Address - Phone:917-698-7614
Mailing Address - Fax:
Practice Address - Street 1:1611 SE BYBEE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5752
Practice Address - Country:US
Practice Address - Phone:971-279-5638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR28808225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist