Healthcare Provider Details

I. General information

NPI: 1649791534
Provider Name (Legal Business Name): CORINNE CRISTINA LAZO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 09/06/2026
Certification Date: 09/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8147 SW SENECA ST
TUALATIN OR
97062-8416
US

IV. Provider business mailing address

6823 SE CARLTON ST
PORTLAND OR
97206-6514
US

V. Phone/Fax

Practice location:
  • Phone: 503-869-7470
  • Fax: 971-358-8082
Mailing address:
  • Phone: 503-869-7470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number14696
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: