Provider Demographics
NPI:1235672270
Name:AUTREY, KAILA (LMT)
Entity Type:Individual
Prefix:
First Name:KAILA
Middle Name:
Last Name:AUTREY
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 1:604 S PONDEROSA ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-6312
Mailing Address - Country:US
Mailing Address - Phone:541-815-8863
Mailing Address - Fax:
Practice Address - Street 1:3 MONROE PKWY
Practice Address - Street 2:SUITE U
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-1486
Practice Address - Country:US
Practice Address - Phone:503-387-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist