Provider Demographics
NPI:1386625010
Name:CANTWELL, KATHRYN RAE (DC)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:RAE
Last Name:CANTWELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:RAE
Other - Last Name:CANTWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:4155 NE THREE MILE LN
Mailing Address - Street 2:UNIT 135
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-9431
Mailing Address - Country:US
Mailing Address - Phone:847-309-3350
Mailing Address - Fax:847-309-3350
Practice Address - Street 1:12325 SW HORIZON BLVD
Practice Address - Street 2:SUITE 223
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9474
Practice Address - Country:US
Practice Address - Phone:847-309-3350
Practice Address - Fax:847-309-3350
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5569111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU30231Medicare UPIN
IL209726Medicare ID - Type Unspecified