Provider Demographics
NPI:1881239002
Name:LEVINE, NATHAN TIO (LMT, MAT, PT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:TIO
Last Name:LEVINE
Suffix:
Gender:M
Credentials:LMT, MAT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 KING STREET
Mailing Address - Street 2:SPACE 1 BOX 396
Mailing Address - City:POWERS
Mailing Address - State:OR
Mailing Address - Zip Code:97466
Mailing Address - Country:US
Mailing Address - Phone:509-322-4897
Mailing Address - Fax:
Practice Address - Street 1:800 KING ST SPC 1
Practice Address - Street 2:
Practice Address - City:POWERS
Practice Address - State:OR
Practice Address - Zip Code:97466-9691
Practice Address - Country:US
Practice Address - Phone:509-322-4897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25035225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist