=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740783190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONIQUE COUNCIL LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2018
-----------------------------------------------------
Last Update Date | 07/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 SW 2ND ST # 2214
-----------------------------------------------------
City | CORVALLIS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97333-4631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-710-9710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2214
-----------------------------------------------------
City | CORVALLIS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97339-2214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-710-9710
-----------------------------------------------------
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 | 22198
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------