Healthcare Provider Details

I. General information

NPI: 1992159610
Provider Name (Legal Business Name): KATHLEEN KLINE, LMT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE ROAD SUITE 701-D
GRESHAM OR
97030
US

IV. Provider business mailing address

12506 SE LINCOLN CT
PORTLAND OR
97233
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-8959
  • Fax: 503-667-3403
Mailing address:
  • Phone: 503-545-0438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number22193
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KATHLEEN SUSAN KLINE
Title or Position: OWNER
Credential: LMT
Phone: 503-545-0438