Provider Demographics
NPI:1396973517
Name:MAHLUM, KYLE DUANE (PT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:DUANE
Last Name:MAHLUM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:1408 N LOUISIANA ST
Practice Address - Street 2:SUITE 104-A
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7167
Practice Address - Country:US
Practice Address - Phone:509-783-1962
Practice Address - Fax:509-783-1706
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60093188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0251343OtherWASHINGTON L&I
WA8561995Medicaid
WAP00742614OtherRR MEDICARE
WA1396973517Medicaid
WAP00742614OtherRR MEDICARE