Healthcare Provider Details

I. General information

NPI: 1609228238
Provider Name (Legal Business Name): DANIELLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

IV. Provider business mailing address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

V. Phone/Fax

Practice location:
  • Phone: 509-760-9947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19777
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier19777
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerOREGON BOARD OF MASSAGE THERAPISTS

VIII. Authorized Official

Name: DANIELLE SUTTON
Title or Position: LMT
Credential:
Phone: 509-760-9947