Provider Demographics
NPI:1538484183
Name:BOGETTI, KYLIE RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:RENEE
Last Name:BOGETTI
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 1:205 NW WALLACE WAY
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-5415
Mailing Address - Country:US
Mailing Address - Phone:503-857-0048
Mailing Address - Fax:
Practice Address - Street 1:5295 NE ELAM YOUNG PKWY STE 150
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7572
Practice Address - Country:US
Practice Address - Phone:503-439-3889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13039225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist