Provider Demographics
NPI:1154606887
Name:ELLISON, HEATHER MARIE (LMT)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:MARIE
Last Name:ELLISON
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 1:22000 WILLAMETTE DR.
Mailing Address - Street 2:#107
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068
Mailing Address - Country:US
Mailing Address - Phone:503-722-8888
Mailing Address - Fax:503-722-9422
Practice Address - Street 1:22000 WILLAMETTE DR.
Practice Address - Street 2:#107
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068
Practice Address - Country:US
Practice Address - Phone:503-722-8888
Practice Address - Fax:503-722-9422
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2017-07-13
Deactivation Date:2016-04-04
Deactivation Code:
Reactivation Date:2017-07-13
Provider Licenses
StateLicense IDTaxonomies
OR15510225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist