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
StateLicense IDTaxonomies
OR6913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01554277OtherRR MEDICARE
OR500648450Medicaid
ORR166205Medicare PIN