Healthcare Provider Details

I. General information

NPI: 1578691697
Provider Name (Legal Business Name): LEESA ANNE WALTERS LAC LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 NW GARFIELD AVE
CORVALLIS OR
97330-2056
US

IV. Provider business mailing address

1230 NW GARFIELD AVE
CORVALLIS OR
97330-2056
US

V. Phone/Fax

Practice location:
  • Phone: 541-738-6117
  • Fax:
Mailing address:
  • Phone: 541-738-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01000
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13160
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: