Provider Demographics
NPI:1679082622
Name:ALBERTUS, CALLIE
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:ALBERTUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10021 NW 307TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PLAINS
Mailing Address - State:OR
Mailing Address - Zip Code:97133-7109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16679 BOONES FERRY RD STE 105
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4378
Practice Address - Country:US
Practice Address - Phone:503-635-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15847225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist