Provider Demographics
NPI:1538547625
Name:WARD, ANGELA DENISE (LMT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DENISE
Last Name:WARD
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 1:412 E MAIN AVE SUITE 1
Mailing Address - Street 2:PO BOX 472
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759
Mailing Address - Country:US
Mailing Address - Phone:541-410-1212
Mailing Address - Fax:541-549-6403
Practice Address - Street 1:412 E MAIN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759
Practice Address - Country:US
Practice Address - Phone:541-410-1212
Practice Address - Fax:541-549-6403
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20341225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist