Provider Demographics
NPI:1659809325
Name:GREENSEA, BERYL (LMT)
Entity Type:Individual
Prefix:
First Name:BERYL
Middle Name:
Last Name:GREENSEA
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 1:5125 SW LOMBARD AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2918
Mailing Address - Country:US
Mailing Address - Phone:202-770-8527
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE STE 315
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5105
Practice Address - Country:US
Practice Address - Phone:503-544-2463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023217172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist