Provider Demographics
NPI:1255667580
Name:CANTRELL, HEATHER MACDONALD (LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MACDONALD
Last Name:CANTRELL
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 1:15880 QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3336
Mailing Address - Country:US
Mailing Address - Phone:971-322-4026
Mailing Address - Fax:
Practice Address - Street 1:15880 QUARRY RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3336
Practice Address - Country:US
Practice Address - Phone:971-322-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7763225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist