Provider Demographics
NPI:1649643768
Name:LUCAS, KAYTLIN (LMT, 21640)
Entity type:Individual
Prefix:
First Name:KAYTLIN
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:LMT, 21640
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 SW OAK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5810
Mailing Address - Country:US
Mailing Address - Phone:971-708-9291
Mailing Address - Fax:
Practice Address - Street 1:3990 COLLINS WAY STE 201
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3459
Practice Address - Country:US
Practice Address - Phone:503-635-1236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21640172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist