Provider Demographics
NPI:1710363106
Name:PASSEY, KYLE (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:PASSEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 NE VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-3827
Mailing Address - Country:US
Mailing Address - Phone:503-489-6250
Mailing Address - Fax:503-489-1650
Practice Address - Street 1:308 N IVY ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3704
Practice Address - Country:US
Practice Address - Phone:503-263-6786
Practice Address - Fax:503-263-6451
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist