Provider Demographics
NPI:1073682019
Name:SHERADEN, TRINITY K (LMT)
Entity Type:Individual
Prefix:
First Name:TRINITY
Middle Name:K
Last Name:SHERADEN
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 1:1085 MONEDA AVE N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-6256
Mailing Address - Country:US
Mailing Address - Phone:503-869-7380
Mailing Address - Fax:866-548-6743
Practice Address - Street 1:2263 NE CORNELL RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5947
Practice Address - Country:US
Practice Address - Phone:503-869-7380
Practice Address - Fax:866-548-6743
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTS1037297OtherASHN CREDENTIALLING #
OR7300OtherMASSAGE LICENSE