Provider Demographics
NPI:1437553195
Name:RUSSELL, STEPHANIE (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:RUSSELL
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 1:7275 SE WRENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-5600
Mailing Address - Country:US
Mailing Address - Phone:503-935-0057
Mailing Address - Fax:
Practice Address - Street 1:6441 SW CANYON CT
Practice Address - Street 2:SUITE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-1458
Practice Address - Country:US
Practice Address - Phone:503-935-0057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13026225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist