Provider Demographics
NPI:1386939411
Name:FORTY, MARIA ELIZABETH (LMT)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ELIZABETH
Last Name:FORTY
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:PO BOX 924
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-0924
Mailing Address - Country:US
Mailing Address - Phone:541-253-6216
Mailing Address - Fax:
Practice Address - Street 1:455 S 4TH ST
Practice Address - Street 2:SUITE #7
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1546
Practice Address - Country:US
Practice Address - Phone:541-253-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16171225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist