Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 20380 | OR |
NPI | 1003205113 |
---|---|
Provider Name | Miss Mariya Zavyalova |
First Address | Portland, OR 97236-4909 |
Second Address | Portland, OR 97205-2629 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2015 |
Last Update Date | 13/01/2015 |