Individual
ETHAN LIVELY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2149 NE BROADWAY ST, PORTLAND, OR 97232-1580
(503) 281-0278
Mailing address
18699 NE MARINE DR SLIP C8, PORTLAND, OR 97230-7359
(859) 802-8089
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
27378
OR
Other
Enumeration date
11/07/2022
Last updated
11/07/2022
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