Healthcare Provider Details

I. General information

NPI: 1699929638
Provider Name (Legal Business Name): LEIGH CHAS WYENBERG LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 HARNEY ST
VANCOUVER WA
98660-2059
US

IV. Provider business mailing address

3110 HARNEY ST
VANCOUVER WA
98660-2059
US

V. Phone/Fax

Practice location:
  • Phone: 541-990-4179
  • Fax:
Mailing address:
  • Phone: 541-990-4179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13938
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: