Provider Demographics
NPI:1285019786
Name:OXENDAHL, TIMOTHY (LMT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:OXENDAHL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7235 N GREENWICH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-5517
Mailing Address - Country:US
Mailing Address - Phone:971-303-3699
Mailing Address - Fax:
Practice Address - Street 1:2906 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3271
Practice Address - Country:US
Practice Address - Phone:503-281-6909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-25
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20646225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist