Provider Demographics
NPI:1750650495
Name:WILLIAMS, SHASTA LEE
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 SE HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-5899
Mailing Address - Country:US
Mailing Address - Phone:503-513-4665
Mailing Address - Fax:
Practice Address - Street 1:3880 SE HARRISON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-5899
Practice Address - Country:US
Practice Address - Phone:503-513-4665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10529225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist