Provider Demographics
NPI:1093411696
Name:CHURCH, KATHRYN ELIZABETH (DPT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:CHURCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15480 SW MALLARD DR STE 103
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-9437
Mailing Address - Country:US
Mailing Address - Phone:541-631-8365
Mailing Address - Fax:
Practice Address - Street 1:11782 SW BARNES RD STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5933
Practice Address - Country:US
Practice Address - Phone:503-214-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist