Provider Demographics
NPI:1982780136
Name:BLACKWOOD, MICHELLE GAULKE (LAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GAULKE
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24850 SE STARK ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8320
Mailing Address - Country:US
Mailing Address - Phone:503-665-9355
Mailing Address - Fax:503-661-3430
Practice Address - Street 1:24850 SE STARK ST SUITE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2656
Practice Address - Country:US
Practice Address - Phone:503-665-9355
Practice Address - Fax:503-661-3430
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00567171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist