Provider Demographics
NPI:1205385879
Name:BENNETT, MICHELLE MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:BENNETT
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 1:14044 CHELSEA DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5760
Mailing Address - Country:US
Mailing Address - Phone:503-515-5579
Mailing Address - Fax:503-697-7810
Practice Address - Street 1:3689 CARMAN DR STE 300
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2620
Practice Address - Country:US
Practice Address - Phone:503-515-5579
Practice Address - Fax:503-697-7810
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21023225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist