Provider Demographics
NPI:1396216792
Name:DANIELS, KIMBERLY DIANE (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:DANIELS
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 1:865 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3303
Mailing Address - Country:US
Mailing Address - Phone:503-263-6895
Mailing Address - Fax:
Practice Address - Street 1:865 NW 6TH AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3303
Practice Address - Country:US
Practice Address - Phone:503-263-6895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty