Healthcare Provider Details

I. General information

NPI: 1447260690
Provider Name (Legal Business Name): WANDA MARIE LOVE LMT CR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SE CEDAR ST
HILLSBORO OR
97123
US

IV. Provider business mailing address

46617 NW HILLSIDE RD
FOREST GROVE OR
97116
US

V. Phone/Fax

Practice location:
  • Phone: 503-619-0408
  • Fax:
Mailing address:
  • Phone: 503-357-5922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10838
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: