Provider Demographics
NPI:1033573340
Name:CALLAHAN, GWEN (LMT)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 SW MORRISON ST
Mailing Address - Street 2:SUITE 411
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2635
Mailing Address - Country:US
Mailing Address - Phone:971-258-2778
Mailing Address - Fax:
Practice Address - Street 1:1017 SW MORRISON ST
Practice Address - Street 2:SUITE 411
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2635
Practice Address - Country:US
Practice Address - Phone:971-258-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17739225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist