Provider Demographics
NPI:1821225251
Name:MALT, KRISTIN ANNE (MSOT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANNE
Last Name:MALT
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NW 8TH AVE
Mailing Address - Street 2:#703
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3553
Mailing Address - Country:US
Mailing Address - Phone:561-308-9734
Mailing Address - Fax:
Practice Address - Street 1:300 NW 8TH AVE
Practice Address - Street 2:#703
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3553
Practice Address - Country:US
Practice Address - Phone:561-308-9734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1024849225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist