=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770960890
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. COREY IONE BURGESS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2015
-----------------------------------------------------
Last Update Date | 05/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1845 HIGHWAY 126 STE A
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97439-9626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-590-7534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8220 171ST AVE NE
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98052-3924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-891-0332
-----------------------------------------------------
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 | MA60560728
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 24788
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------