Healthcare Provider Details

I. General information

NPI: 1407623366
Provider Name (Legal Business Name): VALERIE LEE RENEAU LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 WARTAHOO LN
CANYONVILLE OR
97417-9683
US

IV. Provider business mailing address

PO BOX 1213
MYRTLE CREEK OR
97457-0129
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-8533
  • Fax:
Mailing address:
  • Phone: 541-643-1126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-24993
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: