Provider Demographics
NPI:1104199306
Name:SANDAHL, NICHOLE M (LMT)
Entity Type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:M
Last Name:SANDAHL
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 1:1360 SW 176TH TER
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7562
Mailing Address - Country:US
Mailing Address - Phone:503-933-2112
Mailing Address - Fax:
Practice Address - Street 1:1360 SW 176TH TER
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7562
Practice Address - Country:US
Practice Address - Phone:503-933-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16839225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist