Basic Information
| Provider Information | |||||||||
| NPI: | 1225798556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KELSEE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 578 | ||||||||
| Address2: | |||||||||
| City: | TROUTDALE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970600578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034891174 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1470 NE 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977542906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414476846 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2021 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 64322 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.