Provider Demographics
NPI:1215770839
Name:KENT, SIRI SUNDERTA
Entity type:Individual
Prefix:
First Name:SIRI SUNDERTA
Middle Name:
Last Name:KENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83048 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-9711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 W OREGON AVE
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426-9259
Practice Address - Country:US
Practice Address - Phone:541-895-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist