Provider Demographics
NPI:1972721421
Name:SIDES, M. KARRIE (LMT)
Entity type:Individual
Prefix:
First Name:M. KARRIE
Middle Name:
Last Name:SIDES
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 1:868 SW TROY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4478
Mailing Address - Country:US
Mailing Address - Phone:503-381-2960
Mailing Address - Fax:
Practice Address - Street 1:2161 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1512
Practice Address - Country:US
Practice Address - Phone:503-381-2960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12405225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist