Provider Demographics
NPI:1013776103
Name:JOY, KENDALL T (LMT)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:T
Last Name:JOY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:KENDALL
Other - Middle Name:T
Other - Last Name:JOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:110 SW NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2242
Mailing Address - Country:US
Mailing Address - Phone:541-207-4804
Mailing Address - Fax:
Practice Address - Street 1:2933 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1760
Practice Address - Country:US
Practice Address - Phone:541-207-4804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27174225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist