Provider Demographics
NPI:1134685878
Name:HOPE-GREEN, SHASTA
Entity Type:Individual
Prefix:MISS
First Name:SHASTA
Middle Name:
Last Name:HOPE-GREEN
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 1:13223 NE ONEIL HWY
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-8970
Mailing Address - Country:US
Mailing Address - Phone:503-502-7837
Mailing Address - Fax:
Practice Address - Street 1:150 NE BEND RIVER MALL AVE STE 300
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7553
Practice Address - Country:US
Practice Address - Phone:503-502-7837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023166OtherOREGON STATE BOARD ISSUED LICENSE FOR MASSAGE