Provider Demographics
NPI:1336123280
Name:REED, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:REED
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:REED
Other - Last Name:PRUSYNSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:10215 SW PARKWAY
Practice Address - Street 2:STE D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5036
Practice Address - Country:US
Practice Address - Phone:503-292-3583
Practice Address - Fax:503-292-1022
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR202127Medicaid
OR00WDBBDAMedicare PIN