Provider Demographics
NPI:1013085927
Name:BOHM, KENDRA LEE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:LEE
Last Name:BOHM
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 1:15579 SW 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7980
Mailing Address - Country:US
Mailing Address - Phone:971-219-6427
Mailing Address - Fax:
Practice Address - Street 1:15579 SW 76TH AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7980
Practice Address - Country:US
Practice Address - Phone:971-219-6427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10828174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist