Provider Demographics
NPI:1114552197
Name:MCCOY, DENISE LOUISE (LMT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:LOUISE
Last Name:MCCOY
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 1:35659 SUMMERS LN
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9773
Mailing Address - Country:US
Mailing Address - Phone:541-609-0330
Mailing Address - Fax:
Practice Address - Street 1:529 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4429
Practice Address - Country:US
Practice Address - Phone:541-609-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6438225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist