Provider Demographics
NPI:1831484633
Name:ANDERSON THERAPEUTIC MASSAGE CLINIC
Entity Type:Organization
Organization Name:ANDERSON THERAPEUTIC MASSAGE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-348-4794
Mailing Address - Street 1:200 SW FLORENCE AVE APT D15
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-7127
Mailing Address - Country:US
Mailing Address - Phone:503-348-4794
Mailing Address - Fax:503-667-3403
Practice Address - Street 1:655 NW BURNSIDE RD STE 1
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3745
Practice Address - Country:US
Practice Address - Phone:503-348-4794
Practice Address - Fax:503-667-3403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11-00008345261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service