Provider Demographics
NPI:1659354231
Name:DOHERTY, K'LYN H (OTR, CHT)
Entity Type:Individual
Prefix:
First Name:K'LYN
Middle Name:H
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:OTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 NW FLANDERS ST
Mailing Address - Street 2:STE G-1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3442
Mailing Address - Country:US
Mailing Address - Phone:503-224-9270
Mailing Address - Fax:503-224-9271
Practice Address - Street 1:2330 NW FLANDERS ST
Practice Address - Street 2:STE G-1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3442
Practice Address - Country:US
Practice Address - Phone:503-224-9270
Practice Address - Fax:503-224-9271
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR914557225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230523Medicaid
WA140196OtherWA L&I
WA8419913Medicaid
WA8419913Medicaid