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General NPI Number Information
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NPI Number | 1033663620
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Entity Type | Organization
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Legal Business Name | DEEP GROUND MASSAGE & BODYWORK
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Dates
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Enumeration Date | 08/11/2016
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Last Update Date | 08/11/2016
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Provider Practice Location Address
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Address Line | 1725 SE HAWTHORNE BLVD
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City | PORTLAND
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State | OR
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Zip | 97214-3722
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Country | US
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Telephone | 503-926-4045
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Fax |
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Provider Business Mailing Address
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Address Line | 4935 SE 74TH AVE
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City | PORTLAND
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State | OR
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Zip | 97206-4339
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Country | US
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Telephone | 503-926-4045
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STEPHANIE LAVON TROTTER
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Credential | LMT
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Telephone | 503-926-4045
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 18138
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License Number State | OR
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