Provider Demographics
NPI:1811294838
Name:DANIEL, AUSTIN TYLER (LMT)
Entity type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:TYLER
Last Name:DANIEL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 SE 50TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3827
Mailing Address - Country:US
Mailing Address - Phone:503-871-3183
Mailing Address - Fax:971-302-6629
Practice Address - Street 1:2216 SE 50TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3827
Practice Address - Country:US
Practice Address - Phone:503-871-3183
Practice Address - Fax:971-302-6629
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16840225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist