Provider Demographics
NPI:1447500335
Name:KLANN, HEATHER R (LMT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:R
Last Name:KLANN
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:PO BOX 1381
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-1381
Mailing Address - Country:US
Mailing Address - Phone:503-515-5688
Mailing Address - Fax:
Practice Address - Street 1:417 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7609
Practice Address - Country:US
Practice Address - Phone:503-515-5688
Practice Address - Fax:503-667-3239
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14692225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist