=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962392068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE WELLNESS STUDIO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2025
-----------------------------------------------------
Last Update Date | 07/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35170 BROOTEN RD STE B
-----------------------------------------------------
City | PACIFIC CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97135-8036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-801-6939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 61
-----------------------------------------------------
City | PACIFIC CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97135-0061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-801-6939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LICENSED MASSAGE THERAPIST
-----------------------------------------------------
Name | MS. SHELLEY COLLINS STEPHENS
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 503-801-6939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------