Provider Demographics
NPI:1093348708
Name:BOUSTEAD, BAYLEE MELCINE (LMT)
Entity Type:Individual
Prefix:
First Name:BAYLEE
Middle Name:MELCINE
Last Name:BOUSTEAD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BAYLEE
Other - Middle Name:MELCINE
Other - Last Name:DUNKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:4709 NE 41ST ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-8808
Mailing Address - Country:US
Mailing Address - Phone:360-713-4881
Mailing Address - Fax:
Practice Address - Street 1:114 E HANCOCK ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2822
Practice Address - Country:US
Practice Address - Phone:503-554-0661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT-23832225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist