=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659644177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COCOON MASSAGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2012
-----------------------------------------------------
Last Update Date | 04/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7831 SE STARK ST STE 200
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97215-2357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-266-4162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 818 SW 3RD AVE PMB 263
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-490-1901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ONWER
-----------------------------------------------------
Name | EMILY AMEN
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 971-266-4162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 10253
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------