Healthcare Provider Details

I. General information

NPI: 1831484633
Provider Name (Legal Business Name): ANDERSON THERAPEUTIC MASSAGE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 NW BURNSIDE RD STE 1
GRESHAM OR
97030-3745
US

IV. Provider business mailing address

200 SW FLORENCE AVE APT D15
GRESHAM OR
97080-7127
US

V. Phone/Fax

Practice location:
  • Phone: 503-348-4794
  • Fax: 503-667-3403
Mailing address:
  • Phone: 503-348-4794
  • Fax: 503-667-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number11-00008345
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: TERRI LYNN ANDERSON
Title or Position: MASSAGE THERAPIST/OWNER
Credential: LMT
Phone: 503-348-4794