Provider Demographics
NPI:1497013296
Name:MASSOTHERAPY CLINIC, PC
Entity Type:Organization
Organization Name:MASSOTHERAPY CLINIC, PC
Other - Org Name:SUSANNE CARLSON, PRESIDENT, PROVIDER, ANNE DRYAD, PROVIDER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMT
Authorized Official - Phone:503-226-1948
Mailing Address - Street 1:1220 SW MORRISON SUITE 410
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205
Mailing Address - Country:US
Mailing Address - Phone:503-226-1948
Mailing Address - Fax:503-226-1598
Practice Address - Street 1:1220 SW MORRISON SUITE 410
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205
Practice Address - Country:US
Practice Address - Phone:503-226-1948
Practice Address - Fax:503-226-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1068225700000X
OR1151225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty