Provider Demographics
NPI:1891815288
Name:MAXWELL, SANDRA NMN (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:NMN
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 991
Mailing Address - Street 2:
Mailing Address - City:LORANE
Mailing Address - State:OR
Mailing Address - Zip Code:97451-0991
Mailing Address - Country:US
Mailing Address - Phone:541-942-6946
Mailing Address - Fax:
Practice Address - Street 1:1997 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3521
Practice Address - Country:US
Practice Address - Phone:541-942-6946
Practice Address - Fax:541-349-9581
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2964225700000X
FLMA 7355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist