Provider Demographics
NPI:1770659427
Name:MAUSS, KELLY EILEEN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:EILEEN
Last Name:MAUSS
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:EILEEN
Other - Last Name:DORIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:1109 JADWIN AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3434
Practice Address - Country:US
Practice Address - Phone:509-946-8497
Practice Address - Fax:509-946-8767
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1770659427Medicaid
WA1770659427Medicaid