Healthcare Provider Details

I. General information

NPI: 1104035104
Provider Name (Legal Business Name): TESSARA DYAN BENNETT L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 NW OVERLOOK DR APT 2238
HILLSBORO OR
97124-7670
US

IV. Provider business mailing address

2830 NW OVERLOOK DR APT 2238
HILLSBORO OR
97124-7670
US

V. Phone/Fax

Practice location:
  • Phone: 503-984-3465
  • Fax:
Mailing address:
  • Phone: 503-984-3465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11136
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: