Healthcare Provider Details

I. General information

NPI: 1114687464
Provider Name (Legal Business Name): MARY WINDSOR LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S CENTER ST STE B
SUBLIMITY OR
97385-9100
US

IV. Provider business mailing address

42889 VALLEY VIEW DR
SCIO OR
97374-9318
US

V. Phone/Fax

Practice location:
  • Phone: 503-510-0242
  • Fax:
Mailing address:
  • Phone: 503-510-0242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3756
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: