Healthcare Provider Details

I. General information

NPI: 1245441591
Provider Name (Legal Business Name): AUTUMN M SYKES L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3117 SE MILWAUKIE AVE
PORTLAND OR
97202-2427
US

IV. Provider business mailing address

4409 SE 26TH AVE
PORTLAND OR
97202-4741
US

V. Phone/Fax

Practice location:
  • Phone: 503-236-1200
  • Fax:
Mailing address:
  • Phone: 503-750-6717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10954
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: