Provider Demographics
NPI:1598940918
Name:RADONICH, RACHEL-DOMENIKA (LMT)
Entity Type:Individual
Prefix:
First Name:RACHEL-DOMENIKA
Middle Name:
Last Name:RADONICH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:DOMENIKA
Other - Middle Name:
Other - Last Name:RADONICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1235 SE DIVISION ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1099
Mailing Address - Country:US
Mailing Address - Phone:503-713-3406
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1099
Practice Address - Country:US
Practice Address - Phone:503-713-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10652225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist