Provider Demographics
NPI:1891852224
Name:DISTEFANO, KATHERINE IV
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DISTEFANO
Suffix:IV
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:MCFARLANE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5964 NE 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2373
Mailing Address - Country:US
Mailing Address - Phone:503-544-7810
Mailing Address - Fax:
Practice Address - Street 1:2100 NE BROADWAY ST STE 125
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1500
Practice Address - Country:US
Practice Address - Phone:503-477-8222
Practice Address - Fax:971-373-8648
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11090174400000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist