Provider Demographics
NPI:1932840535
Name:TKACIK, DANIELLE LEE (LMT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LEE
Last Name:TKACIK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:DANIKA
Other - Middle Name:
Other - Last Name:TKACIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:1733 E POWELL BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8013
Mailing Address - Country:US
Mailing Address - Phone:503-740-6343
Mailing Address - Fax:503-974-3744
Practice Address - Street 1:1733 E POWELL BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8013
Practice Address - Country:US
Practice Address - Phone:503-740-6343
Practice Address - Fax:503-974-3744
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26808225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780448878OtherGROUP NPI