Provider Demographics
NPI:1700340601
Name:BIZZELL-MILLER, BREE AUDRESE (LMT)
Entity Type:Individual
Prefix:
First Name:BREE
Middle Name:AUDRESE
Last Name:BIZZELL-MILLER
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 1:936 SE ANKENY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1300
Mailing Address - Country:US
Mailing Address - Phone:503-232-3215
Mailing Address - Fax:
Practice Address - Street 1:936 SE ANKENY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1300
Practice Address - Country:US
Practice Address - Phone:503-232-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist