Provider Demographics
NPI:1164587937
Name:JUDGE, KATHLEEN MARY (LMT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARY
Last Name:JUDGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 NE 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3835
Mailing Address - Country:US
Mailing Address - Phone:503-233-8457
Mailing Address - Fax:
Practice Address - Street 1:3241 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1855
Practice Address - Country:US
Practice Address - Phone:503-282-8582
Practice Address - Fax:503-460-0814
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4731OtherLICENSED MASSAGE THERAPIS
OR30 2373OtherCHIROPRACTIC ASSISTANT