Provider Demographics
NPI:1609168137
Name:KRUSE, KATHERINE IDELL THOMPSON
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:IDELL THOMPSON
Last Name:KRUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 SW KANAN DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-3441
Mailing Address - Country:US
Mailing Address - Phone:503-756-3712
Mailing Address - Fax:
Practice Address - Street 1:4326 SW KANAN DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-3441
Practice Address - Country:US
Practice Address - Phone:503-756-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9687225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist