Provider Demographics
NPI:1467950485
Name:GROGAN, TAWNYA RENEE
Entity Type:Individual
Prefix:
First Name:TAWNYA
Middle Name:RENEE
Last Name:GROGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAWNYA
Other - Middle Name:RENEE
Other - Last Name:GROGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:2448 DRIFT CREEK RD NE
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-9587
Mailing Address - Country:US
Mailing Address - Phone:503-510-1522
Mailing Address - Fax:
Practice Address - Street 1:2455 MCGILCHRIST ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1116
Practice Address - Country:US
Practice Address - Phone:503-510-1522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19490225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty