Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 20920 | OR |
N | 225700000X | Massage Therapist | MT121462 | TX |
N | 226300000X | Kinesiotherapist | 202920 | OR |
N | 226300000X | Kinesiotherapist | MT121462 | TX |
NPI | 1932593688 |
---|---|
Provider Name | Ellen Katherine Smith |
First Address | Portland, OR 97266-3635 |
Second Address | Portland, OR 97266-3635 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2015 |
Last Update Date | 20/03/2015 |