Provider Demographics
NPI:1730431735
Name:SHADBURNE, REBECCA ANN (LMT)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANN
Last Name:SHADBURNE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:501 NE HOOD AVE.
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-674-7894
Mailing Address - Fax:503-674-7899
Practice Address - Street 1:501 NE HOOD AVE.
Practice Address - Street 2:SUITE 205
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-674-7894
Practice Address - Fax:503-674-7899
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19079225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist