Provider Demographics
NPI:1487638276
Name:DOMEYER, KELLY L (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:DOMEYER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BRENDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3270 LIBERTY RD. S.
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-371-0779
Mailing Address - Fax:503-371-0886
Practice Address - Street 1:3270 LIBERTY RD. S.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-371-0779
Practice Address - Fax:503-371-0886
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023002Medicaid
OR130858Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER