Healthcare Provider Details

I. General information

NPI: 1245861913
Provider Name (Legal Business Name): ISABEL ANANDA BURBECK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E BURNSIDE ST STE 213
PORTLAND OR
97214-1768
US

IV. Provider business mailing address

7222 E BURNSIDE ST APT 6
PORTLAND OR
97215-1495
US

V. Phone/Fax

Practice location:
  • Phone: 503-234-4288
  • Fax:
Mailing address:
  • Phone: 503-839-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number15424
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: