Provider Demographics
NPI: | 1508113093 |
---|---|
Name: | WALISH, KYLA JOHANNA (PT) |
Entity Type: | Individual |
Prefix: | |
First Name: | KYLA |
Middle Name: | JOHANNA |
Last Name: | WALISH |
Suffix: | |
Gender: | F |
Credentials: | PT |
Other - Prefix: | |
Other - First Name: | KYLA |
Other - Middle Name: | JOHANNA |
Other - Last Name: | GOODWIN |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | PT |
Mailing Address - Street 1: | 16083 SW UPPER BOONES FERRY RD |
Mailing Address - Street 2: | SUITE 300 |
Mailing Address - City: | TIGARD |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97224-7736 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 800-219-8835 |
Mailing Address - Fax: | 503-639-9699 |
Practice Address - Street 1: | 17355 BOONES FERRY RD |
Practice Address - Street 2: | STE. B |
Practice Address - City: | LAKE OSWEGO |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97035-5202 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-632-0844 |
Practice Address - Fax: | 503-635-0812 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2012-08-14 |
Last Update Date: | 2016-01-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 6913 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | P01554277 | Other | RR MEDICARE |
OR | 500648450 | Medicaid | |
OR | R166205 | Medicare PIN |