=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801639075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAURA T. KUBLY, LMT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2024
-----------------------------------------------------
Last Update Date | 06/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1318 NW 20TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97209-1671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-332-4330
-----------------------------------------------------
Fax | 503-498-5339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7622 SE STEPHENS ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97215-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-332-4330
-----------------------------------------------------
Fax | 503-498-5339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LAURA KUBLY
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 608-332-4330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------