Provider Demographics
NPI:1437854213
Name:BENNETT, KELLY ALYSA (LMT, BCTMB)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ALYSA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15390 SW KENTON DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7371
Mailing Address - Country:US
Mailing Address - Phone:503-639-8768
Mailing Address - Fax:
Practice Address - Street 1:12725 SW 66TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2548
Practice Address - Country:US
Practice Address - Phone:971-245-5699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26594225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist