Provider Demographics
NPI:1073236949
Name:COLVIN-WALTERS, MELISSA E (LMT, PTA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:E
Last Name:COLVIN-WALTERS
Suffix:
Gender:F
Credentials:LMT, PTA
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:E
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT PTA
Mailing Address - Street 1:20429 PATSY DR
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-9077
Mailing Address - Country:US
Mailing Address - Phone:503-705-6616
Mailing Address - Fax:
Practice Address - Street 1:15840 SE 114TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9024
Practice Address - Country:US
Practice Address - Phone:503-705-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6930225200000X
ORLMT-26105225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant