Provider Demographics
NPI:1164867578
Name:BURCH, SHAROLE KIMBERLY (LMT)
Entity Type:Individual
Prefix:
First Name:SHAROLE
Middle Name:KIMBERLY
Last Name:BURCH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SHAROLE
Other - Middle Name:LYNN
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:5087 SW EVELYN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5867
Mailing Address - Country:US
Mailing Address - Phone:503-206-8947
Mailing Address - Fax:
Practice Address - Street 1:5087 SW EVELYN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5867
Practice Address - Country:US
Practice Address - Phone:503-206-8947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16556225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist