Provider Demographics
NPI:1326564782
Name:STALEY, CAITLIN ELIZABETH
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ELIZABETH
Last Name:STALEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8026 DIVISION RD
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-1153
Mailing Address - Country:US
Mailing Address - Phone:541-390-6242
Mailing Address - Fax:
Practice Address - Street 1:310 CRATER LAKE AVE STE 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6857
Practice Address - Country:US
Practice Address - Phone:541-210-5674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023555225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist