Provider Demographics
NPI:1578059572
Name:KAWECKI, KAYLA JADE (LMT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:JADE
Last Name:KAWECKI
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 1:9629 WAGNER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-7802
Mailing Address - Country:US
Mailing Address - Phone:541-930-0882
Mailing Address - Fax:
Practice Address - Street 1:258 A STREET
Practice Address - Street 2:SUITE 21
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540
Practice Address - Country:US
Practice Address - Phone:541-301-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22110225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1363556OtherAMERICAN MASSAGE THERAPY ASSOCIATION