MEDICARE: MS. MARY M DALTON MASSAGE THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	4417	OR

General Provider Information

NPI Number	:	1659562247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY M DALTON MASSAGE THERAPY

Provider Business Mailing Address
First Line	:	12950 SW PACIFIC HWY STE 115
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-5052
Country	:	US
Telephone Number	:	503-620-0724
Fax Number	:

Provider Business Practice Location Address
First Line	:	8879 SW CENTER ST
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-6461
Country	:	US
Telephone Number	:	503-620-0724
Fax Number	:	503-624-2177

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	03/01/2021

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