Provider Demographics
NPI:1144850074
Name:WADE, KEIRSTALYN (MSOT, OTR/L, CSRS)
Entity type:Individual
Prefix:
First Name:KEIRSTALYN
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:MSOT, OTR/L, CSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10315 NE TANASBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7836
Mailing Address - Country:US
Mailing Address - Phone:315-491-3362
Mailing Address - Fax:
Practice Address - Street 1:5335 NE IRVING ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3157
Practice Address - Country:US
Practice Address - Phone:315-491-3362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR426621225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist