Provider Demographics
NPI:1770222853
Name:THORSEN, KJELL M (DPT)
Entity Type:Individual
Prefix:MR
First Name:KJELL
Middle Name:M
Last Name:THORSEN
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:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0066
Mailing Address - Country:US
Mailing Address - Phone:541-476-4010
Mailing Address - Fax:541-474-6310
Practice Address - Street 1:1328 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1255
Practice Address - Country:US
Practice Address - Phone:541-476-4010
Practice Address - Fax:541-474-6310
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR64526OtherBOARD OF PHYSICAL THERAPY