Provider Demographics
NPI:1558542795
Name:LEDERLE, KATIE J (BA)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:J
Last Name:LEDERLE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2148 NE 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4617
Mailing Address - Country:US
Mailing Address - Phone:720-938-0896
Mailing Address - Fax:
Practice Address - Street 1:7455 SW BEVELAND RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8610
Practice Address - Country:US
Practice Address - Phone:503-624-2600
Practice Address - Fax:503-624-7752
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator