Ethan Lively
Massage Therapist in Portland, OR. Individual provider (NPI-1).
NPI number1841908001
StatusActive
Last updated in NPPESNov 7, 2022
Details
- NPI
- 1841908001
- Entity type
- Individual (NPI-1)
- Name
- Ethan Lively
- Sex
- Male
- Sole proprietor
- No
- Enumeration date
- Nov 7, 2022
- Certification date
- Nov 7, 2022
- Last updated
- Nov 7, 2022
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 225700000X | Massage Therapist | 27378 | OR | Yes |
Practice location
2149 Ne Broadway StPortland, OR 97232-1580
Phone 503-281-0278
Mailing address
18699 Ne Marine Dr Slip C8Portland, OR 97230-7359
Phone 859-802-8089
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