Provider Demographics
NPI:1154874535
Name:HANTHORN, MARISSA (ND, LAC)
Entity type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:
Last Name:HANTHORN
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9009 SE ADAMS ST UNIT 3344
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-1180
Mailing Address - Country:US
Mailing Address - Phone:971-222-6506
Mailing Address - Fax:
Practice Address - Street 1:1330 SE CESAR E CHAVEZ BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4322
Practice Address - Country:US
Practice Address - Phone:503-232-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC195483171100000X
OR22305225700000X
OR4341175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty