Healthcare Provider Details

I. General information

NPI: 1487107058
Provider Name (Legal Business Name): TANYA MCCLINTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 S MACADAM AVE STE 130
PORTLAND OR
97239-3800
US

IV. Provider business mailing address

5200 S MACADAM AVE STE 130
PORTLAND OR
97239-3800
US

V. Phone/Fax

Practice location:
  • Phone: 503-206-0300
  • Fax:
Mailing address:
  • Phone: 503-206-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number22516
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: