Provider Demographics
NPI:1770839581
Name:DRAKE, KALA RAJELLE (LMT)
Entity Type:Individual
Prefix:
First Name:KALA
Middle Name:RAJELLE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28784 SW ASHLAND LOOP APT 203
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-8796
Mailing Address - Country:US
Mailing Address - Phone:503-899-9428
Mailing Address - Fax:
Practice Address - Street 1:30050 SW TOWN CENTER LOOP W
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-7596
Practice Address - Country:US
Practice Address - Phone:503-685-9841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17594225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist