Provider Demographics
NPI:1669844171
Name:HULL, MCKENZIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:HULL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 NW NAITO PKWY STE 185
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2535
Mailing Address - Country:US
Mailing Address - Phone:971-983-5260
Mailing Address - Fax:971-983-5326
Practice Address - Street 1:19250 SW 65TH AVE STE 125
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-413-4505
Practice Address - Fax:503-413-4719
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056011253225X00000X
OR349715225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500760019Medicaid