Healthcare Provider Details

I. General information

NPI: 1003205113
Provider Name (Legal Business Name): MARIYA ZAVYALOVA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 SW MORRISON ST STE 411
PORTLAND OR
97205-2629
US

IV. Provider business mailing address

12711 SE LYDIA CT
PORTLAND OR
97236-4909
US

V. Phone/Fax

Practice location:
  • Phone: 503-806-7763
  • Fax:
Mailing address:
  • Phone: 503-806-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number20380
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: