Provider Demographics
NPI:1205443298
Name:MADDEN, KATE
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:MADDEN
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 1:1748 NW FAIRVIEW DR # A
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3842
Mailing Address - Country:US
Mailing Address - Phone:503-724-0378
Mailing Address - Fax:
Practice Address - Street 1:1748 NW FAIRVIEW DR # A
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3842
Practice Address - Country:US
Practice Address - Phone:503-492-3910
Practice Address - Fax:503-674-6706
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21477405300000X, 246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR21477OtherLMT