MEDICARE: MICHAELA A KISTLER OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	01054648	OR
2	225XP0200X	Pediatric Occupational Therapist

General Provider Information

NPI Number	:	1912037110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAELA A KISTLER OT

Provider Business Mailing Address
First Line	:	2029 NE CESAR E CHAVEZ BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5305
Country	:	US
Telephone Number	:	503-869-8545
Fax Number	:

Provider Business Practice Location Address
First Line	:	2029 NE CESAR E CHAVEZ BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5305
Country	:	US
Telephone Number	:	503-869-8545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	08/08/2025

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