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General NPI Number Information
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NPI Number | 1750459673
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Entity Type | Individual
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Provider Name | LAURA LYNN WALICZEK DPT
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Gender | Female
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Dates
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Enumeration Date | 11/30/2006
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Last Update Date | 12/28/2021
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Provider Practice Location Address
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Address Line | 9860 SW HALL BLVD #A3
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City | TIGARD
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State | OR
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Zip | 97223-8896
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Country | US
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Telephone | 503-902-2123
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Fax |
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Provider Business Mailing Address
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Address Line | 664 SW RUSTICA TERRACE
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City | PORTLAND
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State | OR
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Zip | 97225
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Country | US
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Telephone | 503-902-2123
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 4954
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License Number State | OR
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