Provider Demographics
NPI:1386983435
Name:INTHAVONG, ONEDONNA (LMT)
Entity type:Individual
Prefix:
First Name:ONEDONNA
Middle Name:
Last Name:INTHAVONG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:INTHAVONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:8885 SW CANYON RD
Mailing Address - Street 2:SUITE 129
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-3431
Mailing Address - Country:US
Mailing Address - Phone:503-260-7574
Mailing Address - Fax:
Practice Address - Street 1:8885 SW CANYON RD
Practice Address - Street 2:SUITE129
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-3431
Practice Address - Country:US
Practice Address - Phone:503-260-7574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-10
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5513225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist