Healthcare Provider Details

I. General information

NPI: 1205443298
Provider Name (Legal Business Name): KATE MADDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 NW FAIRVIEW DR # A
GRESHAM OR
97030-3842
US

IV. Provider business mailing address

1748 NW FAIRVIEW DR # A
GRESHAM OR
97030-3842
US

V. Phone/Fax

Practice location:
  • Phone: 503-492-3910
  • Fax: 503-674-6706
Mailing address:
  • Phone: 503-724-0378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number21477
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number21477
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: