Provider Demographics
NPI:1396177895
Name:ACKLEY, SERENITY CELESTIA (LMT)
Entity Type:Individual
Prefix:MISS
First Name:SERENITY
Middle Name:CELESTIA
Last Name:ACKLEY
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 1:210 SW EDGEWAY DR
Mailing Address - Street 2:APT J 186
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-3978
Mailing Address - Country:US
Mailing Address - Phone:503-422-9497
Mailing Address - Fax:
Practice Address - Street 1:15110 BOONES FERRY RD
Practice Address - Street 2:SUITE 100C
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3468
Practice Address - Country:US
Practice Address - Phone:503-422-9497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist