Provider Demographics
NPI:1235474891
Name:MCCOY, CAHTI-JO (LMT)
Entity type:Individual
Prefix:
First Name:CAHTI-JO
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10480 SW EASTRIDGE ST
Mailing Address - Street 2:#18
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5018
Mailing Address - Country:US
Mailing Address - Phone:503-490-2790
Mailing Address - Fax:
Practice Address - Street 1:14619 SW TEAL BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-6194
Practice Address - Country:US
Practice Address - Phone:503-746-6585
Practice Address - Fax:503-746-6583
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18103225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist