Provider Demographics
NPI:1003358441
Name:MEADOWS, MICHELLE JEAN (MA 60623545)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEAN
Last Name:MEADOWS
Suffix:
Gender:F
Credentials:MA 60623545
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 EVERGREEN WAY
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671
Mailing Address - Country:US
Mailing Address - Phone:503-449-1322
Mailing Address - Fax:
Practice Address - Street 1:2804 SE LINCOLN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-449-1322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60623545225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist