Provider Demographics
NPI:1902827025
Name:DESHAW, HOLLEY JEAN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:HOLLEY
Middle Name:JEAN
Last Name:DESHAW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:MOUNT ANGEL
Mailing Address - State:OR
Mailing Address - Zip Code:97362-0315
Mailing Address - Country:US
Mailing Address - Phone:503-407-1821
Mailing Address - Fax:
Practice Address - Street 1:559 GLATT CIR
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9675
Practice Address - Country:US
Practice Address - Phone:503-981-4591
Practice Address - Fax:503-982-3308
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10890225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist