=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629321997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEAGAN ANNE FREED LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2012
-----------------------------------------------------
Last Update Date | 06/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2505 SE 11TH AVE STE 356
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-921-0914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5421 SE 86TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97266-4701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-921-0914
-----------------------------------------------------
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 | 14982
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------