Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 25028 | OR |
NPI | 1003466962 |
---|---|
Provider Name | Amanda Richardson |
First Address | Eugene, OR 97405-2253 |
Second Address | Eugene, OR 97401-3523 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2019 |
Last Update Date | 12/09/2019 |