Provider Demographics
NPI:1962017459
Name:DOUGLAS, KAITLYN (LMT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:DOUGLAS
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 1:3246 NE 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1849
Mailing Address - Country:US
Mailing Address - Phone:971-270-6064
Mailing Address - Fax:
Practice Address - Street 1:7817 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-2339
Practice Address - Country:US
Practice Address - Phone:503-975-5298
Practice Address - Fax:503-546-7496
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25073225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist