Provider Demographics
NPI:1568270189
Name:GARBODEN, ALEX DANJAI WYATT (LMT)
Entity type:Individual
Prefix:MR
First Name:ALEX
Middle Name:DANJAI WYATT
Last Name:GARBODEN
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 1:102 NE LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7918
Mailing Address - Country:US
Mailing Address - Phone:503-883-1692
Mailing Address - Fax:
Practice Address - Street 1:102 NE LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7918
Practice Address - Country:US
Practice Address - Phone:503-883-1692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR28631225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist