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General NPI Number Information
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NPI Number | 1639438419
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Entity Type | Organization
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Legal Business Name | JANICE MODESITT LMT
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Dates
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Enumeration Date | 05/14/2012
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Last Update Date | 05/14/2012
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Provider Practice Location Address
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Address Line | 16463 BOONES FERRY RD STE. 100
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-4259
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Country | US
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Telephone | 503-699-2955
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Fax |
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Provider Business Mailing Address
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Address Line | 16463 BOONES FERRY RD STE. 100
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-4259
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Country | US
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Telephone | 503-699-2955
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Fax |
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Authorized Official
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Title or Position | LICENSED MASSAGE THERAPIST
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Name | MRS. JANICE CAROLE MODESITT
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Credential | L.M.T.
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Telephone | 503-699-2955
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1045
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License Number State | OR
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