Provider Demographics
NPI:1023512233
Name:VAN DER WERF, ANDREW RUSSELL (LMT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:RUSSELL
Last Name:VAN DER WERF
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12600 SE HAROLD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4225
Mailing Address - Country:US
Mailing Address - Phone:775-400-6619
Mailing Address - Fax:
Practice Address - Street 1:2526 NE 15TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4222
Practice Address - Country:US
Practice Address - Phone:503-288-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23850225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist