Provider Demographics
NPI:1912319203
Name:TAYSOM, LIETA KATHLEEN (LMT)
Entity Type:Individual
Prefix:
First Name:LIETA
Middle Name:KATHLEEN
Last Name:TAYSOM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8051
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-0051
Mailing Address - Country:US
Mailing Address - Phone:509-469-1903
Mailing Address - Fax:509-469-1903
Practice Address - Street 1:1775 WASHBURN WAY
Practice Address - Street 2:SUITE A.
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4304
Practice Address - Country:US
Practice Address - Phone:541-887-2507
Practice Address - Fax:541-887-2508
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20367225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist