Healthcare Provider Details

I. General information

NPI: 1467999581
Provider Name (Legal Business Name): STEPHANIE LYN ROSS L.M.T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4253 SE 182ND AVE
GRESHAM OR
97030-5083
US

IV. Provider business mailing address

4253 SE 182ND AVE
GRESHAM OR
97030-5083
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-5090
  • Fax: 503-489-2320
Mailing address:
  • Phone: 503-661-5090
  • Fax: 503-489-2320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number11569
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: