Basic Information
| Provider Information | |||||||||
| NPI: | 1760806798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCHARD | ||||||||
| FirstName: | MAGGIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MCGOUGAN | ||||||||
| OtherFirstName: | MAGGIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2925 RIVER RD S | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973023677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035854824 | ||||||||
| FaxNumber: | 5033702545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2014 | ||||||||
| LastUpdateDate: | 02/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 20421 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.