Basic Information
| Provider Information | |||||||||
| NPI: | 1215116637 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKKEN | ||||||||
| FirstName: | KELSY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8669 SW HOLLY ST | ||||||||
| Address2: | #110 | ||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970708628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084451166 | ||||||||
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| Practice Location | |||||||||
| Address1: | 290 MOYER LN NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973043822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033708990 | ||||||||
| FaxNumber: | 5033634214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 233451 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.