Provider Demographics
NPI:1124436316
Name:DEVEREAUX, KATHERINE MICHELLE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MICHELLE
Last Name:DEVEREAUX
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 1:1109 NE ROSELAWN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4452
Mailing Address - Country:US
Mailing Address - Phone:775-230-2201
Mailing Address - Fax:
Practice Address - Street 1:1109 NE ROSELAWN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-4452
Practice Address - Country:US
Practice Address - Phone:775-230-2201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1590235Z00000X
OR015325235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist