Healthcare Provider Details

I. General information

NPI: 1033054317
Provider Name (Legal Business Name): KELLY HUSTON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9923 SW ARCTIC DR
BEAVERTON OR
97005-4194
US

IV. Provider business mailing address

10500 NE FARGO ST # B
PORTLAND OR
97220-2755
US

V. Phone/Fax

Practice location:
  • Phone: 503-358-6008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number29327
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: