Healthcare Provider Details

I. General information

NPI: 1518503358
Provider Name (Legal Business Name): HOLLIE HEFFERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 NE 2ND ST
GRESHAM OR
97030-7512
US

IV. Provider business mailing address

915 NE 2ND ST
GRESHAM OR
97030-7512
US

V. Phone/Fax

Practice location:
  • Phone: 503-558-4977
  • Fax: 971-253-4445
Mailing address:
  • Phone: 503-558-4977
  • Fax: 971-253-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number61009426
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number25231
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: