Provider Demographics
NPI:1912281189
Name:POWELL-STORMBERG, ASHA RAE (LMT)
Entity Type:Individual
Prefix:
First Name:ASHA
Middle Name:RAE
Last Name:POWELL-STORMBERG
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 1:19230 MCLOUGHLIN BLVD
Mailing Address - Street 2:B
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-2625
Mailing Address - Country:US
Mailing Address - Phone:503-449-5164
Mailing Address - Fax:503-210-0528
Practice Address - Street 1:19230 MCLOUGHLIN BLVD
Practice Address - Street 2:B
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2625
Practice Address - Country:US
Practice Address - Phone:503-449-5164
Practice Address - Fax:503-210-0528
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17528225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist