=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548072499
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ETHAN BOSWELL LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2025
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12750 SW 2ND ST STE 203
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-2779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-228-1122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16593 NW OAK CREEK DR
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-7479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-954-6193
-----------------------------------------------------
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 | 28815
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------