Healthcare Provider Details

I. General information

NPI: 1659562247
Provider Name (Legal Business Name): MARY M DALTON MASSAGE THERAPY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8879 SW CENTER ST
TIGARD OR
97223-6461
US

IV. Provider business mailing address

12950 SW PACIFIC HWY STE 115
TIGARD OR
97223-5052
US

V. Phone/Fax

Practice location:
  • Phone: 503-620-0724
  • Fax: 503-624-2177
Mailing address:
  • Phone: 503-620-0724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4417
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: