=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952731291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAUNNA DIANN STELZENMUELLER LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2013
-----------------------------------------------------
Last Update Date | 11/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10915 SE STARK ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97216-3348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-261-1120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1932 SE 100TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97216-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-929-3115
-----------------------------------------------------
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 | 12815
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------