Healthcare Provider Details

I. General information

NPI: 1679224034
Provider Name (Legal Business Name): AMANDA KOBELSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11565 SW DURHAM RD UNIT 110
TIGARD OR
97224
US

IV. Provider business mailing address

11565 SW DURHAM RD STE 110
TIGARD OR
97224-3553
US

V. Phone/Fax

Practice location:
  • Phone: 503-639-0778
  • Fax:
Mailing address:
  • Phone: 503-639-0778
  • Fax: 503-639-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number26618
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: