Provider Demographics
NPI:1215116637
Name:BAKKEN, KELSY MARIE (COTA)
Entity type:Individual
Prefix:
First Name:KELSY
Middle Name:MARIE
Last Name:BAKKEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8669 SW HOLLY ST
Mailing Address - Street 2:#110
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-8628
Mailing Address - Country:US
Mailing Address - Phone:608-445-1166
Mailing Address - Fax:
Practice Address - Street 1:290 MOYER LN NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3822
Practice Address - Country:US
Practice Address - Phone:503-370-8990
Practice Address - Fax:503-363-4214
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR233451224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant