Provider Demographics
NPI:1255731808
Name:GREATHOUSE, KELLY (MOT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GREATHOUSE
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 NE 66TH AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3078
Mailing Address - Country:US
Mailing Address - Phone:360-885-4684
Mailing Address - Fax:360-882-8972
Practice Address - Street 1:8339 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-2215
Practice Address - Country:US
Practice Address - Phone:503-245-5639
Practice Address - Fax:503-245-6013
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR330982225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist