Provider Demographics
NPI:1942760426
Name:WILEY, EMMA ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:ELIZABETH
Last Name:WILEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:ELIZABETH
Other - Last Name:KUPCHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-1805
Mailing Address - Country:US
Mailing Address - Phone:907-750-2835
Mailing Address - Fax:
Practice Address - Street 1:508 WASHINGTON ST STE 13
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2232
Practice Address - Country:US
Practice Address - Phone:541-316-0787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24999225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist