Provider Demographics
NPI:1114169901
Name:KILLINGSWORTH, BRENDA KAY (LMT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:KILLINGSWORTH
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 1:14925 SW 133RD AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-1604
Mailing Address - Country:US
Mailing Address - Phone:503-307-9894
Mailing Address - Fax:
Practice Address - Street 1:14925 SW 133RD AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-1604
Practice Address - Country:US
Practice Address - Phone:503-307-9894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15772174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR15772OtherOREGON MASSAGE BOARD