Provider Demographics
NPI:1174196034
Name:GAMBLE, KATHLEEN SUSANNE (THW, PSS)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:SUSANNE
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:THW, PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 875
Mailing Address - Street 2:
Mailing Address - City:MILL CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97360-0875
Mailing Address - Country:US
Mailing Address - Phone:971-388-8841
Mailing Address - Fax:
Practice Address - Street 1:280 NE SANTIAM BLVD
Practice Address - Street 2:
Practice Address - City:MILL CITY
Practice Address - State:OR
Practice Address - Zip Code:97360
Practice Address - Country:US
Practice Address - Phone:971-332-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR105011175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR105011OtherOREGON HEALTH ASSOCIATION