Provider Demographics
NPI:1245372127
Name:BUCKINGHAM, THEA DANIELLE (LMT, LMP)
Entity type:Individual
Prefix:MS
First Name:THEA
Middle Name:DANIELLE
Last Name:BUCKINGHAM
Suffix:
Gender:F
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-2332
Mailing Address - Country:US
Mailing Address - Phone:503-853-6327
Mailing Address - Fax:
Practice Address - Street 1:306 OAK ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1719
Practice Address - Country:US
Practice Address - Phone:503-873-3641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8290225700000X
WAMA00016429225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist