Provider Demographics
NPI:1619178787
Name:MICHAELS, SCOTT DAVID (LAC, LMT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DAVID
Last Name:MICHAELS
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23785 E BENCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RHODODENDRON
Mailing Address - State:OR
Mailing Address - Zip Code:97049-9712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19201 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5291
Practice Address - Country:US
Practice Address - Phone:503-293-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4452225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist