Provider Demographics
NPI:1558716902
Name:HEITZHAUSEN, KATHRYN MACLEOD (PSYD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MACLEOD
Last Name:HEITZHAUSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:HEITZHAUSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 16308
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0308
Mailing Address - Country:US
Mailing Address - Phone:503-427-2394
Mailing Address - Fax:
Practice Address - Street 1:12570 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-2550
Practice Address - Country:US
Practice Address - Phone:503-427-2394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
OR3363103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program