Provider Demographics
NPI:1356934640
Name:BUTTERFIELD, KELLY MEGAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MEGAN
Last Name:BUTTERFIELD
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 1:7105 SW GARDEN HOME RD APT 30
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-9576
Mailing Address - Country:US
Mailing Address - Phone:503-998-1955
Mailing Address - Fax:
Practice Address - Street 1:16320 BRYANT RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4308
Practice Address - Country:US
Practice Address - Phone:503-908-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22579225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist