Provider Demographics
NPI:1992171730
Name:CHILDS, MELISSA E
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:E
Last Name:CHILDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 W POWELL BLVD APT E236
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-6514
Mailing Address - Country:US
Mailing Address - Phone:541-880-8233
Mailing Address - Fax:
Practice Address - Street 1:1217 NW BURNSIDE RD STE 701
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:541-880-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21590225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist