Healthcare Provider Details

I. General information

NPI: 1962999128
Provider Name (Legal Business Name): TEDDY WHITE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15220 NW GREENBRIER PKWY STE 260
BEAVERTON OR
97006-8111
US

IV. Provider business mailing address

7350 SW 102ND AVE
BEAVERTON OR
97008-6513
US

V. Phone/Fax

Practice location:
  • Phone: 503-439-9494
  • Fax:
Mailing address:
  • Phone: 971-242-9229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18376
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: