Provider Demographics
NPI:1578512380
Name:BOYSEN, KERRY LYNNE HERTEL (DPT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNNE HERTEL
Last Name:BOYSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 NW CIRCLE BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1410
Mailing Address - Country:US
Mailing Address - Phone:541-908-7959
Mailing Address - Fax:541-207-3062
Practice Address - Street 1:966 NW CIRCLE BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1410
Practice Address - Country:US
Practice Address - Phone:541-908-7959
Practice Address - Fax:541-207-3062
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5873-24225100000X
OR4130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230574Medicaid