Provider Demographics
NPI:1215407473
Name:OLSEN, KASSANDRA (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 S CORBETT AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3559
Mailing Address - Country:US
Mailing Address - Phone:415-250-0161
Mailing Address - Fax:
Practice Address - Street 1:19945 SW BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7272
Practice Address - Country:US
Practice Address - Phone:415-250-0161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
OR10021225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist