Provider Demographics
NPI:1184096372
Name:KING, HELENLISLE (PT)
Entity type:Individual
Prefix:
First Name:HELENLISLE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 SW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-8123
Mailing Address - Country:US
Mailing Address - Phone:802-338-1309
Mailing Address - Fax:
Practice Address - Street 1:404 NE PENN AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-318-7041
Practice Address - Fax:541-388-3711
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61385225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500696238Medicaid
OR500696238Medicaid