Provider Demographics
NPI:1417277740
Name:SAMUELSON, HEIDI LEONARD (LMT)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:LEONARD
Last Name:SAMUELSON
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 1:241 NW DENNIS AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-2916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5295 NE ELAM YOUNG PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7567
Practice Address - Country:US
Practice Address - Phone:503-530-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10994174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10994OtherOREGON MASSAGE THERAPY LICENSE