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General NPI Number Information
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NPI Number | 1780990630
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Entity Type | Organization
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Legal Business Name | MICHELLE DENISE ROBERTS
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Dates
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Enumeration Date | 08/28/2010
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Last Update Date | 07/09/2013
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Provider Practice Location Address
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Address Line | 2100 SE LAKE RD SUITE 2B
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City | MILWAUKIE
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State | OR
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Zip | 97222-7759
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Country | US
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Telephone | 503-490-2693
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 SE LAKE RD STE 2B
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City | MILWAUKIE
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State | OR
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Zip | 97222-7759
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/LMT
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Name | MICHELLE DENISE ROBERTS
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Credential | LMT
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Telephone | 503-490-2693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 15528
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License Number State | OR
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