Provider Demographics
NPI:1770941338
Name:GILLIS, TYSANDRA (LMT)
Entity type:Individual
Prefix:
First Name:TYSANDRA
Middle Name:
Last Name:GILLIS
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 1:859 MULE DEER ST.
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304
Mailing Address - Country:US
Mailing Address - Phone:971-301-9826
Mailing Address - Fax:
Practice Address - Street 1:859 MULE DEER ST.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304
Practice Address - Country:US
Practice Address - Phone:971-301-9826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20948225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist