Provider Demographics
NPI:1346464419
Name:STREET, CHARLES WILLIAM (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:STREET
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 SW 170TH AVE UNIT 200
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-8089
Mailing Address - Country:US
Mailing Address - Phone:541-778-0705
Mailing Address - Fax:541-608-3911
Practice Address - Street 1:1060 SW 170TH AVE UNIT 200
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8089
Practice Address - Country:US
Practice Address - Phone:541-778-0705
Practice Address - Fax:541-608-3911
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist