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General NPI Number Information
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NPI Number | 1346724283
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Entity Type | Individual
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Provider Name | DEVON MARIE BRUCKNER LMT
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Gender | Female
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Dates
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Enumeration Date | 09/17/2018
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Last Update Date | 09/25/2019
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Provider Practice Location Address
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Address Line | 289 E ELLENDALE AVE STE 101
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City | DALLAS
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State | OR
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Zip | 97338-1500
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Country | US
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Telephone | 503-623-9676
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 NW ADAMS ST. UNIT C
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City | MCMINNVILLE
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State | OR
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Zip | 97128
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Country | US
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Telephone | 971-237-5901
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 22789
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License Number State | OR
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