Provider Demographics
NPI:1497283386
Name:SANDIDGE, KACIE LYNNE (LMT)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:LYNNE
Last Name:SANDIDGE
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 1:418 BEAVERCREEK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4287
Mailing Address - Country:US
Mailing Address - Phone:503-723-4462
Mailing Address - Fax:
Practice Address - Street 1:418 BEAVERCREEK RD STE 102
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4287
Practice Address - Country:US
Practice Address - Phone:503-723-4462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22295225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist