Provider Demographics
NPI:1508057878
Name:BISSONNETTE, MELANIE RUTH (LMT)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:RUTH
Last Name:BISSONNETTE
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 1:8532 N IVANHOE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4827
Mailing Address - Country:US
Mailing Address - Phone:503-267-0853
Mailing Address - Fax:
Practice Address - Street 1:8532 N IVANHOE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4827
Practice Address - Country:US
Practice Address - Phone:503-267-0853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-02
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11999174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist