Healthcare Provider Details

I. General information

NPI: 1841479243
Provider Name (Legal Business Name): CYNTHIA J WYLER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4927 NE 30TH AVE
PORTLAND OR
97211-7007
US

IV. Provider business mailing address

4512 SE WOODSTOCK BLVD
PORTLAND OR
97206-6274
US

V. Phone/Fax

Practice location:
  • Phone: 503-281-0681
  • Fax: 503-335-6258
Mailing address:
  • Phone: 503-777-2776
  • Fax: 503-777-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6264
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: