Provider Demographics
NPI:1437363942
Name:CHARLSTON, KEVIN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CHARLSTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 N WATTS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-6835
Mailing Address - Country:US
Mailing Address - Phone:971-221-3082
Mailing Address - Fax:
Practice Address - Street 1:1111 NE 99TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-216-5434
Practice Address - Fax:503-216-5420
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist