Provider Demographics
NPI:1821750597
Name:WONDERWHEEL, SAVANNA (LMT)
Entity Type:Individual
Prefix:
First Name:SAVANNA
Middle Name:
Last Name:WONDERWHEEL
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 1:915 SE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2913
Mailing Address - Country:US
Mailing Address - Phone:707-490-2916
Mailing Address - Fax:
Practice Address - Street 1:3810 SE DIVISION ST STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1678
Practice Address - Country:US
Practice Address - Phone:971-645-7576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22738225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist