Provider Demographics
NPI:1346213204
Name:DEDA, MARYA EDEN (LAC, LMT)
Entity Type:Individual
Prefix:
First Name:MARYA
Middle Name:EDEN
Last Name:DEDA
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2933 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1760
Mailing Address - Country:US
Mailing Address - Phone:503-282-2268
Mailing Address - Fax:503-282-2863
Practice Address - Street 1:2933 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1760
Practice Address - Country:US
Practice Address - Phone:503-282-2268
Practice Address - Fax:503-282-2863
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00978171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist