Provider Demographics
NPI:1336420124
Name:KIESEL, CHRISTYNA
Entity Type:Individual
Prefix:
First Name:CHRISTYNA
Middle Name:
Last Name:KIESEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:
Practice Address - Street 1:996 NW CIRCLE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1485
Practice Address - Country:US
Practice Address - Phone:541-757-0878
Practice Address - Fax:541-757-0879
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60126762225X00000X
OR243593225X00000X
MT1108225X00000X
ID225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR180482Medicare PIN