Provider Demographics
NPI:1760861041
Name:KUSHNIRYUK, TATYANA (LMT)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:KUSHNIRYUK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TATYANA
Other - Middle Name:
Other - Last Name:VELICHKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:17221 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-1240
Mailing Address - Country:US
Mailing Address - Phone:503-760-0778
Mailing Address - Fax:503-760-0753
Practice Address - Street 1:17221 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1240
Practice Address - Country:US
Practice Address - Phone:503-760-0778
Practice Address - Fax:503-760-0753
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18813225700000X, 173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173000000XOther Service ProvidersLegal Medicine