Provider Demographics
NPI:1265738272
Name:KINSELLA, SHAWN P (LAC, LMT)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:P
Last Name:KINSELLA
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3743 SE CORA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3237
Mailing Address - Country:US
Mailing Address - Phone:310-488-0949
Mailing Address - Fax:
Practice Address - Street 1:3605 SE 26TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2953
Practice Address - Country:US
Practice Address - Phone:503-234-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17765225700000X
ORAC202894171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty