Provider Demographics
NPI:1386638781
Name:PORTMANN, LAURIE CHRISTINE (MSPT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:CHRISTINE
Last Name:PORTMANN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W MEDICAL CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1767
Mailing Address - Country:US
Mailing Address - Phone:940-692-4688
Mailing Address - Fax:940-692-8388
Practice Address - Street 1:1 W MEDICAL CT
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-1767
Practice Address - Country:US
Practice Address - Phone:940-692-4688
Practice Address - Fax:940-692-8388
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1115632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659654OtherBCBS
TX610485Medicare ID - Type Unspecified