Provider Demographics
NPI:1184141764
Name:MITITIERO, MORIAH ROSE
Entity type:Individual
Prefix:
First Name:MORIAH
Middle Name:ROSE
Last Name:MITITIERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2579 NW IVY WAY
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-9821
Mailing Address - Country:US
Mailing Address - Phone:541-409-9055
Mailing Address - Fax:
Practice Address - Street 1:716 SW HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-3120
Practice Address - Country:US
Practice Address - Phone:541-409-9055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2024-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023347225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist