Provider Demographics
NPI:1912037110
Name:KISTLER, MICHAELA A (OT)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:A
Last Name:KISTLER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 NE 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1332
Mailing Address - Country:US
Mailing Address - Phone:503-287-7258
Mailing Address - Fax:
Practice Address - Street 1:5220 NE SACRAMENTO ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2666
Practice Address - Country:US
Practice Address - Phone:971-888-5265
Practice Address - Fax:971-888-5266
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR01054648225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WCKDKMedicare ID - Type Unspecified