Provider Demographics
NPI:1912778168
Name:DAVIS, CAROLINE ELYSE (LMT)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ELYSE
Last Name:DAVIS
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 1:208 A ST
Mailing Address - Street 2:
Mailing Address - City:VERNONIA
Mailing Address - State:OR
Mailing Address - Zip Code:97064-1304
Mailing Address - Country:US
Mailing Address - Phone:713-972-5697
Mailing Address - Fax:
Practice Address - Street 1:446 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4187
Practice Address - Country:US
Practice Address - Phone:713-972-5697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORLMT-22777OtherSTATE LICENSE