Healthcare Provider Details

I. General information

NPI: 1508302241
Provider Name (Legal Business Name): KELLY L VON BARGEN PTA, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

IV. Provider business mailing address

287 NE 3RD ST APT 209
GRESHAM OR
97030-7722
US

V. Phone/Fax

Practice location:
  • Phone: 971-206-2314
  • Fax:
Mailing address:
  • Phone: 971-361-6349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number22780
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number09654
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: