Healthcare Provider Details

I. General information

NPI: 1205969391
Provider Name (Legal Business Name): MASSAGE ENVY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6395 KEIZER STATION BLVD #103
KEIZER OR
97303-0000
US

IV. Provider business mailing address

6675 HIDDEN CREEK LOOP NE
KEIZER OR
97303-7882
US

V. Phone/Fax

Practice location:
  • Phone: 503-589-1597
  • Fax:
Mailing address:
  • Phone: 503-409-1851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12558
License Number StateOR

VIII. Authorized Official

Name: STEPHANIE RENE LAWRENCE
Title or Position: LICENSED MASSAGE THERAPY
Credential: LMT
Phone: 503-589-1597