Provider Demographics
NPI:1477070043
Name:GATES, CASEY TYRONE (LMT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:TYRONE
Last Name:GATES
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 SE YAMHILL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4447
Mailing Address - Country:US
Mailing Address - Phone:971-413-3106
Mailing Address - Fax:
Practice Address - Street 1:3109 NE BROADWAY ST STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1812
Practice Address - Country:US
Practice Address - Phone:971-413-3106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023247225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist