Provider Demographics
NPI:1437648409
Name:DAVIS, SPENCER TODD (LMT)
Entity Type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:TODD
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22000 WILLAMETTE DR STE 107
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3210
Mailing Address - Country:US
Mailing Address - Phone:503-722-8888
Mailing Address - Fax:
Practice Address - Street 1:22000 WILLAMETTE DR STE 107
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3210
Practice Address - Country:US
Practice Address - Phone:503-722-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-05
Last Update Date:2018-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23590225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR23590OtherOREGON BOARD OF MASSAGE