Provider Demographics
NPI:1114090784
Name:BODE, MICHELLE KATHLEEN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:BODE
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 1:1950 CAMBRIA PL
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-2643
Mailing Address - Country:US
Mailing Address - Phone:541-767-0700
Mailing Address - Fax:541-767-0700
Practice Address - Street 1:1950 CAMBRIA PL
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2643
Practice Address - Country:US
Practice Address - Phone:541-767-0700
Practice Address - Fax:541-767-0700
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8191225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist