Provider Demographics
NPI:1275978686
Name:GLASS, STEPHANIE J (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:GLASS
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 1:6555 N FENWICK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4951
Mailing Address - Country:US
Mailing Address - Phone:503-880-8905
Mailing Address - Fax:
Practice Address - Street 1:6555 N FENWICK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4951
Practice Address - Country:US
Practice Address - Phone:503-880-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7544225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist