Healthcare Provider Details

I. General information

NPI: 1356687115
Provider Name (Legal Business Name): CONCETTA M ANTONELLI LMT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 B AVE STE L
LAKE OSWEGO OR
97034-3011
US

IV. Provider business mailing address

11375 SE 33RD AVE
MILWAUKIE OR
97222-6754
US

V. Phone/Fax

Practice location:
  • Phone: 503-349-7038
  • Fax:
Mailing address:
  • Phone: 503-349-7038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number7449
License Number StateOR

VIII. Authorized Official

Name: MS. CONCETTA MARIE ANTONELLI
Title or Position: MASSAGE THERAPIST
Credential: LMT
Phone: 503-349-7038