Provider Demographics
NPI:1124326046
Name:KRASSELT, KATHLEEN (MT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KRASSELT
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 E HIST COL RVR HWY
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-2075
Mailing Address - Country:US
Mailing Address - Phone:503-442-1815
Mailing Address - Fax:
Practice Address - Street 1:389 E HIST COL RVR HWY
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-2075
Practice Address - Country:US
Practice Address - Phone:503-442-1815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15568174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist