Provider Demographics
NPI:1730666777
Name:ROBERTS, MICHELLE EMBREE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:EMBREE
Last Name:ROBERTS
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 1:1673 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103
Mailing Address - Country:US
Mailing Address - Phone:503-791-8311
Mailing Address - Fax:
Practice Address - Street 1:679 E HARBOR DR # 140
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-9717
Practice Address - Country:US
Practice Address - Phone:503-861-1661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15290225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA$$$$$$$$$OtherPI