Provider Demographics
NPI:1275283996
Name:BACON, HALEY (LMT)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:BACON
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 1:500 N COLUMBIA RIVER HWY STE 410
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-1203
Mailing Address - Country:US
Mailing Address - Phone:503-410-5623
Mailing Address - Fax:
Practice Address - Street 1:500 N COLUMBIA RIVER HWY STE 410
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1203
Practice Address - Country:US
Practice Address - Phone:503-410-5623
Practice Address - Fax:503-410-5672
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26921225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist