Provider Demographics
NPI:1336782929
Name:FOUTCH, MELISSA (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FOUTCH
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 1:10175 SW BARBUR BLVD STE 309B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5947
Mailing Address - Country:US
Mailing Address - Phone:503-739-3907
Mailing Address - Fax:
Practice Address - Street 1:10175 SW BARBUR BLVD STE 309B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5947
Practice Address - Country:US
Practice Address - Phone:503-739-3907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22388225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22388OtherOREGON MASSAGE THERAPY LICENSE