Healthcare Provider Details

I. General information

NPI: 1023221728
Provider Name (Legal Business Name): GARY LEROY WASS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 SW MULTNOMAH BLVD STE 207
PORTLAND OR
97219-4072
US

IV. Provider business mailing address

2929 SW MULTNOMAH BLVD STE 207
PORTLAND OR
97219-4072
US

V. Phone/Fax

Practice location:
  • Phone: 509-240-6989
  • Fax:
Mailing address:
  • Phone: 509-240-6989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00016138
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: