Provider Demographics
NPI:1134321441
Name:O'DONNELL-PETERS, STEPHANIE KIRSTEN
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:KIRSTEN
Last Name:O'DONNELL-PETERS
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 1:1340 N KILLINGSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4565
Mailing Address - Country:US
Mailing Address - Phone:541-979-0315
Mailing Address - Fax:
Practice Address - Street 1:3 MONROE PKWY STE U
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8875
Practice Address - Country:US
Practice Address - Phone:541-979-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18043225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist