Provider Demographics
NPI:1275042673
Name:KELLY, KATE (LMT)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:KELLY
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 1:115 NE MASON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3416
Mailing Address - Country:US
Mailing Address - Phone:503-381-1380
Mailing Address - Fax:
Practice Address - Street 1:3934 NE MLK BLVD STE 108
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-1153
Practice Address - Country:US
Practice Address - Phone:503-381-1380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22806225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22806OtherLMT