Healthcare Provider Details

I. General information

NPI: 1770764797
Provider Name (Legal Business Name): CONCETTA MARIE ANTONELLI L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 AVENUE F
LAKE OSWEGO OR
97034
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 Code225700000X
TaxonomyMassage Therapist
License Number7449
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: