Provider Demographics
NPI:1912316340
Name:BAME, LORI RENEE (PTA)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:RENEE
Last Name:BAME
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9470 COUNTY ROAD 60
Mailing Address - Street 2:
Mailing Address - City:DOLA
Mailing Address - State:OH
Mailing Address - Zip Code:45835-9717
Mailing Address - Country:US
Mailing Address - Phone:567-674-0608
Mailing Address - Fax:
Practice Address - Street 1:1045 DEARBAUGH AVE
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-9245
Practice Address - Country:US
Practice Address - Phone:419-738-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA02178225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant