Provider Demographics
NPI:1114671989
Name:ROBERTS, AILEA
Entity Type:Individual
Prefix:
First Name:AILEA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7337 NE FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5839
Mailing Address - Country:US
Mailing Address - Phone:503-327-3819
Mailing Address - Fax:503-286-7939
Practice Address - Street 1:7337 NE FREMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-5839
Practice Address - Country:US
Practice Address - Phone:503-327-3819
Practice Address - Fax:503-286-7939
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26672225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist