Active NPI
Kimberly Ann Petesky, LMT
- Massage Therapist
- Salem, OR
National Provider Identifier
1104522937
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Massage Therapist
- License
- 27221
- Practice address
- 4356 Commercial St SE
Salem, OR 97302-3914 - Phone
- (503) 689-1216
- NPI assigned
- Feb 2, 2023
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Massage Therapist | 225700000X | 27221 | OR | Primary |
Addresses
Primary practice location
4356 Commercial St SE
Salem, OR 97302-3914
Mailing address
5134 Linda CT SE
Salem, OR 97306-1789
Phone (503) 551-6110
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 27221 | OR | MD | Massage Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Willamette Valley Wellness LLC | Massage Therapist | Current | Accepting new patients |
Locations
4356 Commercial St SE
Salem, OR 97302
Phone (503) 383-9375
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1675296000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1675296000000",
"number": "1104522937",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5134 LINDA CT SE",
"city": "SALEM",
"state": "OR",
"postal_code": "973061789",
"telephone_number": "503-551-6110"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4356 COMMERCIAL ST SE",
"city": "SALEM",
"state": "OR",
"postal_code": "973023914",
"telephone_number": "503-689-1216"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETESKY",
"first_name": "KIMBERLY",
"middle_name": "ANN",
"credential": "LMT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2023-02-02",
"last_updated": "2023-02-02",
"certification_date": "2023-02-02",
"status": "A"
},
"taxonomies": [
{
"code": "225700000X",
"taxonomy_group": "",
"desc": "Massage Therapist",
"state": "OR",
"license": "27221",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Salem, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 2, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.