Provider Demographics
NPI:1194929414
Name:MASSIE, RAECHEL JENNIFER (MPT)
Entity type:Individual
Prefix:MS
First Name:RAECHEL
Middle Name:JENNIFER
Last Name:MASSIE
Suffix:
Gender:F
Credentials:MPT
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 278
Mailing Address - Street 2:
Mailing Address - City:NEHALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97131-0278
Mailing Address - Country:US
Mailing Address - Phone:503-368-4978
Mailing Address - Fax:503-368-4979
Practice Address - Street 1:278 ROWE STREET
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:OR
Practice Address - Zip Code:97147
Practice Address - Country:US
Practice Address - Phone:503-368-4978
Practice Address - Fax:503-368-4979
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR920195896OtherREGENCE BLUE CROSS BLUE S
OR920195896OtherREGENCE BLUE CROSS BLUE S