Provider Demographics
NPI:1053683300
Name:THORNTON, MICHELLE RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:THORNTON
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 1:906 SW ALDER ST UNIT 17
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OR
Mailing Address - Zip Code:97115-9776
Mailing Address - Country:US
Mailing Address - Phone:503-332-5522
Mailing Address - Fax:
Practice Address - Street 1:21974 NE HIGHWAY 240
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-6859
Practice Address - Country:US
Practice Address - Phone:503-550-5083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18568225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1396029914OtherMASSAGE THERAPY