Provider Demographics
NPI:1497080147
Name:WOODSIDE, KATHLEEN IRENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:IRENE
Last Name:WOODSIDE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 SW MAIN ST
Mailing Address - Street 2:104
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1124
Mailing Address - Country:US
Mailing Address - Phone:503-454-6784
Mailing Address - Fax:
Practice Address - Street 1:2153 SW MAIN ST
Practice Address - Street 2:104
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1124
Practice Address - Country:US
Practice Address - Phone:503-454-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018322103TC0700X
OR2572103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical