Provider Demographics
NPI:1265820690
Name:GREEN-BOSTWICK, HEATHER (LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GREEN-BOSTWICK
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 1:4201 CHAPMAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5562
Mailing Address - Country:US
Mailing Address - Phone:503-954-0580
Mailing Address - Fax:
Practice Address - Street 1:4201 CHAPMAN WAY
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5562
Practice Address - Country:US
Practice Address - Phone:503-954-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19356225700000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist