Healthcare Provider Details

I. General information

NPI: 1285794271
Provider Name (Legal Business Name): MICHELLE RENEE SHIELDS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE R ROBLES LMT

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 SW CORBETT AVE CORBETT HILL WELLNESS CENTER
PORTLAND OR
97239
US

IV. Provider business mailing address

1030 COLUMBIA AVE
GLADSTONE OR
97027
US

V. Phone/Fax

Practice location:
  • Phone: 503-225-9033
  • Fax: 503-225-9039
Mailing address:
  • Phone: 503-722-9760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7699
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: