Healthcare Provider Details

I. General information

NPI: 1669763777
Provider Name (Legal Business Name): MICHELLE FRAY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30789 SW BOONES FERRY RD SUITE P
WILSONVILLE OR
97070-7842
US

IV. Provider business mailing address

30789 SW BOONES FERRY RD SUITE P
WILSONVILLE OR
97070-7842
US

V. Phone/Fax

Practice location:
  • Phone: 503-682-6778
  • Fax: 503-682-6744
Mailing address:
  • Phone: 503-682-6778
  • Fax: 503-682-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13860
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: