Provider Demographics
NPI:1699976290
Name:PONTIUS, JUDITH IRENE (LMT)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:IRENE
Last Name:PONTIUS
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 1:4047 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1152
Mailing Address - Country:US
Mailing Address - Phone:503-705-0934
Mailing Address - Fax:
Practice Address - Street 1:4047 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1152
Practice Address - Country:US
Practice Address - Phone:503-705-0934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10774225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist