Provider Demographics
NPI:1285993311
Name:PURDOM, AMIE L (LMT)
Entity type:Individual
Prefix:MS
First Name:AMIE
Middle Name:L
Last Name:PURDOM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:AMIE
Other - Middle Name:L
Other - Last Name:LEFFLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 NW WALL ST
Mailing Address - Street 2:SUITE #100
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3200
Mailing Address - Country:US
Mailing Address - Phone:541-389-4321
Mailing Address - Fax:
Practice Address - Street 1:55 NW WALL ST
Practice Address - Street 2:SUITE #100
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3200
Practice Address - Country:US
Practice Address - Phone:541-389-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16677225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist