Healthcare Provider Details

I. General information

NPI: 1346156817
Provider Name (Legal Business Name): BRANDON MARKEITH GUIDRY LMT#29563
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 S 2ND ST STE C
INDEPENDENCE OR
97351-2030
US

IV. Provider business mailing address

212 JACOBSON WAY S
MONMOUTH OR
97361-2501
US

V. Phone/Fax

Practice location:
  • Phone: 971-465-9711
  • Fax:
Mailing address:
  • Phone: 971-465-9711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number29563
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: