Provider Demographics
NPI:1619248218
Name:OVERBY, KATHRYN MARY (LMT)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:MARY
Last Name:OVERBY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1172
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-1172
Mailing Address - Country:US
Mailing Address - Phone:503-680-9457
Mailing Address - Fax:
Practice Address - Street 1:29781 SW TOWN CENTER LOOP W
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-8806
Practice Address - Country:US
Practice Address - Phone:503-680-9457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5303225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist