Provider Demographics
NPI:1104251727
Name:CHASSEREAU, KATHRYN (LMT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:CHASSEREAU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-0650
Mailing Address - Country:US
Mailing Address - Phone:541-698-8409
Mailing Address - Fax:541-247-9509
Practice Address - Street 1:29846 ELLENSBURG AVE
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-0650
Practice Address - Country:US
Practice Address - Phone:541-698-8409
Practice Address - Fax:541-247-9509
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15866174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR15866OtherMASSAGE LICENSE