Healthcare Provider Details

I. General information

NPI: 1336420124
Provider Name (Legal Business Name): CHRISTYNA KIESEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

996 NW CIRCLE BLVD STE 101
CORVALLIS OR
97330-1485
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD STE 300
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 541-757-0878
  • Fax: 541-757-0879
Mailing address:
  • Phone: 800-219-8835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number60126762
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number243593
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1108
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: