Provider Demographics
NPI:1629211073
Name:WORTMAN, RELISSA LINN (NCTMB)
Entity Type:Individual
Prefix:
First Name:RELISSA
Middle Name:LINN
Last Name:WORTMAN
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1191
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-9191
Mailing Address - Country:US
Mailing Address - Phone:541-398-1085
Mailing Address - Fax:
Practice Address - Street 1:502 WASHINGTON ST STE 210
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2270
Practice Address - Country:US
Practice Address - Phone:541-398-1085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
53764707225700000X
OR14372225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist