=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285419051
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE KAY MCBRIDE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2023
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15455 NW GREENBRIER PKWY STE 250
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-8116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-248-0068
-----------------------------------------------------
Fax | 971-256-9922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 295
-----------------------------------------------------
City | MANZANITA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97130-0295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-341-3130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 20577
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------