Provider Demographics
NPI:1245962653
Name:WOOD, KATHERINE L
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:L
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2808 NE MARTIN LUTHER KING BLVD STE M
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3061
Mailing Address - Country:US
Mailing Address - Phone:971-270-0535
Mailing Address - Fax:971-369-9809
Practice Address - Street 1:2808 NE MARTIN LUTHER KING BLVD STE M
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3061
Practice Address - Country:US
Practice Address - Phone:971-270-0535
Practice Address - Fax:971-369-9809
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHP-R-2005101YP2500X
221700000X
ORR8611101YP2500X
WAMC61466384101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500820108Medicaid