Provider Demographics
NPI:1285054783
Name:BIRCH, LAWRENCE AUSTIN (LMT)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:AUSTIN
Last Name:BIRCH
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 1:1590 COUGAR CT SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-4878
Mailing Address - Country:US
Mailing Address - Phone:541-344-7534
Mailing Address - Fax:
Practice Address - Street 1:1215 MAIN STREET
Practice Address - Street 2:STE 106
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370
Practice Address - Country:US
Practice Address - Phone:541-344-7534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19963225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist