Provider Demographics
NPI:1609122241
Name:REAL, DENISE MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:REAL
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 1:2020 NE LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-5262
Mailing Address - Country:US
Mailing Address - Phone:503-505-2088
Mailing Address - Fax:
Practice Address - Street 1:6125 NE CORNELL RD
Practice Address - Street 2:SUITE 250
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5412
Practice Address - Country:US
Practice Address - Phone:503-530-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18452225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist