Provider Demographics
NPI:1194149880
Name:LEE-REAVIS, LARA (OTR/L)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:LEE-REAVIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12175 ORRS CORNER RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-9545
Mailing Address - Country:US
Mailing Address - Phone:541-224-3391
Mailing Address - Fax:
Practice Address - Street 1:12175 ORRS CORNER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-9545
Practice Address - Country:US
Practice Address - Phone:541-224-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1066356225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist