Provider Demographics
NPI:1821385154
Name:HUIBREGTSE, KATIE NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:NICOLE
Last Name:HUIBREGTSE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:117 S 2ND ST
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-1307
Practice Address - Country:US
Practice Address - Phone:509-697-9109
Practice Address - Fax:509-697-9122
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT30212286225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00969335OtherRR MEDICARE
WA1821385154Medicaid
WAP00969335OtherRR MEDICARE