Provider Demographics
NPI:1043739980
Name:WILEY, HANNAH ELISABETH (LMT)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:ELISABETH
Last Name:WILEY
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 1:1464 GEORGE TWEED BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-6394
Mailing Address - Country:US
Mailing Address - Phone:541-441-3264
Mailing Address - Fax:
Practice Address - Street 1:901 BRUTSCHER ST STE 208
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-6097
Practice Address - Country:US
Practice Address - Phone:503-538-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023534225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist