Provider Demographics
NPI:1285042598
Name:RICHARDSON-RAY, KEATON (PT, DPT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:KEATON
Middle Name:
Last Name:RICHARDSON-RAY
Suffix:
Gender:F
Credentials:PT, DPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 SE TACOMA ST UNIT 122
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6639
Mailing Address - Country:US
Mailing Address - Phone:971-361-9442
Mailing Address - Fax:888-645-6068
Practice Address - Street 1:1327 SE TACOMA ST UNIT 122
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6639
Practice Address - Country:US
Practice Address - Phone:971-361-9442
Practice Address - Fax:888-645-6068
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR112514Medicare PIN