Provider Demographics
NPI:1588918114
Name:GREEN, KYLE (PT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SW 10TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2700
Mailing Address - Country:US
Mailing Address - Phone:503-294-7463
Mailing Address - Fax:
Practice Address - Street 1:4876 NW BETHANY BLVD
Practice Address - Street 2:SUITE L-1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-9259
Practice Address - Country:US
Practice Address - Phone:503-466-2254
Practice Address - Fax:503-466-1143
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60040225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500654087Medicaid
OR500654087Medicaid