Provider Demographics
NPI:1700246063
Name:BRANNAN, STEPHANIE (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BRANNAN
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 1:14871 NW KYLE PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-9247
Mailing Address - Country:US
Mailing Address - Phone:503-954-6955
Mailing Address - Fax:
Practice Address - Street 1:14871 NW KYLE PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-9247
Practice Address - Country:US
Practice Address - Phone:503-954-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22014225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist