Provider Demographics
NPI:1154043222
Name:CANTRELL, JOEY ROBERT (LMT)
Entity type:Individual
Prefix:
First Name:JOEY
Middle Name:ROBERT
Last Name:CANTRELL
Suffix:
Gender:M
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 778
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:OR
Mailing Address - Zip Code:97048-0778
Mailing Address - Country:US
Mailing Address - Phone:503-556-4233
Mailing Address - Fax:
Practice Address - Street 1:500 N COLUMBIA RIVER HWY STE 410
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1203
Practice Address - Country:US
Practice Address - Phone:503-410-5623
Practice Address - Fax:503-410-5672
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist