Healthcare Provider Details

I. General information

NPI: 1548685803
Provider Name (Legal Business Name): KIMBERLY HOOSER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 SE 15TH DR
GRESHAM OR
97080-2984
US

IV. Provider business mailing address

270 NE 181ST AVE
PORTLAND OR
97230-6663
US

V. Phone/Fax

Practice location:
  • Phone: 503-984-6191
  • Fax:
Mailing address:
  • Phone: 503-669-1966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number19701
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: