Provider Demographics
NPI:1003490012
Name:BAZE, KAYLEE (COTA)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:BAZE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KAYLEE
Other - Middle Name:
Other - Last Name:BAZE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:334 EAGLES WING ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4263
Mailing Address - Country:US
Mailing Address - Phone:503-871-8586
Mailing Address - Fax:
Practice Address - Street 1:4515 SUNNYSIDE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3954
Practice Address - Country:US
Practice Address - Phone:503-370-8285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR426792224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant