Provider Demographics
NPI:1396419735
Name:CARBIN, KIESA RENE
Entity Type:Individual
Prefix:
First Name:KIESA
Middle Name:RENE
Last Name:CARBIN
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 1:1550 SE LAVA DR APT 17
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-3401
Mailing Address - Country:US
Mailing Address - Phone:310-210-2063
Mailing Address - Fax:
Practice Address - Street 1:1413 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3640
Practice Address - Country:US
Practice Address - Phone:503-841-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25668225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist