Provider Demographics
NPI:1376981969
Name:CASE, KATHERINE ANN (L,MT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:CASE
Suffix:
Gender:F
Credentials:L,MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 SE WAVERLEIGH BLVD APT 16
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1971
Mailing Address - Country:US
Mailing Address - Phone:503-764-9092
Mailing Address - Fax:
Practice Address - Street 1:5336 SE BUSH ST
Practice Address - Street 2:BLUE ROOM
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-5394
Practice Address - Country:US
Practice Address - Phone:503-764-9092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17912225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist