Healthcare Provider Details

I. General information

NPI: 1104807585
Provider Name (Legal Business Name): VICTORIA GRACE MOSSE MA, ATC,PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 SE ANKENY ST
PORTLAND OR
97214-1448
US

IV. Provider business mailing address

7108 N IVANHOE ST
PORTLAND OR
97203-3943
US

V. Phone/Fax

Practice location:
  • Phone: 503-546-0620
  • Fax: 503-546-0620
Mailing address:
  • Phone: 503-289-6361
  • Fax: 503-546-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT 503236
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: