Provider Demographics
NPI:1487351144
Name:BOGUE, KATHRYN RUUD (LMT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:RUUD
Last Name:BOGUE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:JO
Other - Last Name:RUUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:22703 NE WORTHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:YACOLT
Mailing Address - State:WA
Mailing Address - Zip Code:98675-4741
Mailing Address - Country:US
Mailing Address - Phone:971-645-7171
Mailing Address - Fax:
Practice Address - Street 1:17030 SE 1ST ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-9840
Practice Address - Country:US
Practice Address - Phone:360-604-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61393035225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist