=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447968938
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICAELA WHITTINGTON LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2022
-----------------------------------------------------
Last Update Date | 11/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1134 SE CENTENNIAL CT
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-710-2658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1604 LUND RD
-----------------------------------------------------
City | LA PINE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97739-9107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-536-4902
-----------------------------------------------------
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 | 27016
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------