Provider Demographics
NPI:1598034092
Name:KOLB, AUDREY JEAN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:JEAN
Last Name:KOLB
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 1:3737 NE 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5722
Mailing Address - Country:US
Mailing Address - Phone:971-212-4702
Mailing Address - Fax:
Practice Address - Street 1:790 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7616
Practice Address - Country:US
Practice Address - Phone:503-970-0147
Practice Address - Fax:503-618-0148
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16306225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist