Provider Demographics
NPI:1629404629
Name:HENKEL, AMY ELLEN (LMT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELLEN
Last Name:HENKEL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELLEN
Other - Last Name:BRATVOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:960 S BROADWAY AVE STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3667
Practice Address - Country:US
Practice Address - Phone:208-433-9211
Practice Address - Fax:208-443-9241
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS - 996225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist