Provider Demographics
NPI:1619532231
Name:HENRITZY, CHANCE COLTRANE
Entity Type:Individual
Prefix:
First Name:CHANCE
Middle Name:COLTRANE
Last Name:HENRITZY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 SE MILWAUKIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-4773
Mailing Address - Country:US
Mailing Address - Phone:503-853-6687
Mailing Address - Fax:
Practice Address - Street 1:1421 SE ANKENY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1471
Practice Address - Country:US
Practice Address - Phone:503-284-6996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21918225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist