Provider Demographics
NPI:1962455154
Name:HERNANDEZ, MELISSA (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:HERNANDEZ
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 1:1601 WEBB LAKE DR NE
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-2513
Mailing Address - Country:US
Mailing Address - Phone:503-873-8748
Mailing Address - Fax:503-873-7560
Practice Address - Street 1:224 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381
Practice Address - Country:US
Practice Address - Phone:503-873-6464
Practice Address - Fax:503-873-7560
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6984225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist