Healthcare Provider Details

I. General information

NPI: 1265820690
Provider Name (Legal Business Name): HEATHER GREEN-BOSTWICK L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 CHAPMAN WAY
LAKE OSWEGO OR
97035-5562
US

IV. Provider business mailing address

4201 CHAPMAN WAY
LAKE OSWEGO OR
97035-5562
US

V. Phone/Fax

Practice location:
  • Phone: 503-954-0580
  • Fax:
Mailing address:
  • Phone: 503-954-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number19356
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19356
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: