Provider Demographics
NPI:1912298928
Name:GREN, EMBER
Entity Type:Individual
Prefix:
First Name:EMBER
Middle Name:
Last Name:GREN
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 1:3811 SE 134TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3507
Mailing Address - Country:US
Mailing Address - Phone:503-309-1239
Mailing Address - Fax:
Practice Address - Street 1:3811 SE 134TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3507
Practice Address - Country:US
Practice Address - Phone:503-309-1239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17562225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist