Provider Demographics
NPI:1437730025
Name:BRADLEY, KRISTIN N (LMT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:N
Last Name:BRADLEY
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 1:5120 N INTERSTATE AVE APT 403
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3785
Mailing Address - Country:US
Mailing Address - Phone:503-354-7824
Mailing Address - Fax:
Practice Address - Street 1:1427 NW 23RD AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2645
Practice Address - Country:US
Practice Address - Phone:503-354-7824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24448225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist