Provider Demographics
NPI:1174217335
Name:DOETSCH, KYLEE
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:DOETSCH
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 1:655 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97446-9552
Mailing Address - Country:US
Mailing Address - Phone:208-512-9710
Mailing Address - Fax:
Practice Address - Street 1:655 N 8TH ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:OR
Practice Address - Zip Code:97446-9552
Practice Address - Country:US
Practice Address - Phone:208-512-9710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist