Provider Demographics
NPI:1477571800
Name:LYTTLE, KATHERINE A (PT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:LYTTLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:A
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 3808
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3808
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:
Practice Address - Street 1:1130 NW 22ND AVE STE 345
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2978
Practice Address - Country:US
Practice Address - Phone:503-413-7513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR172196Medicare PIN