Provider Demographics
NPI:1912410911
Name:CARTER, KEZIAH JOY (LMT)
Entity Type:Individual
Prefix:
First Name:KEZIAH
Middle Name:JOY
Last Name:CARTER
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 1:6334 N DEPAUW ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5124
Mailing Address - Country:US
Mailing Address - Phone:503-853-1131
Mailing Address - Fax:
Practice Address - Street 1:6510 NE SISKIYOU ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4572
Practice Address - Country:US
Practice Address - Phone:503-290-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23490225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty