Provider Demographics
NPI:1508286287
Name:WEARSCH, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:WEARSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7409 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7409 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2432
Practice Address - Country:US
Practice Address - Phone:503-956-9396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19867225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist