Provider Demographics
NPI:1164940839
Name:BEDSOLE, STEFANIE GORDON (LMT)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:GORDON
Last Name:BEDSOLE
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:PO BOX 322
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261-0322
Mailing Address - Country:US
Mailing Address - Phone:
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:503-387-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23202225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist