Provider Demographics
NPI:1861706905
Name:PACKARD, AMBER (LMT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:PACKARD
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 1:1904 SE 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3229
Mailing Address - Country:US
Mailing Address - Phone:503-867-3146
Mailing Address - Fax:
Practice Address - Street 1:4246 SE BELMONT ST
Practice Address - Street 2:SUITE #5
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1676
Practice Address - Country:US
Practice Address - Phone:503-445-8114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16158172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist