Provider Demographics
NPI:1013192517
Name:KING, KATHLEEN ELIZABETH (LAC, PTA)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:KING
Suffix:
Gender:F
Credentials:LAC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 SW 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2411
Mailing Address - Country:US
Mailing Address - Phone:503-294-7420
Mailing Address - Fax:503-294-7411
Practice Address - Street 1:1111 SW 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2411
Practice Address - Country:US
Practice Address - Phone:503-294-7420
Practice Address - Fax:503-294-7411
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7946225200000X
ORAC01174171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant