Provider Demographics
NPI:1609919737
Name:MOEN, KATHRYN L (PT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:MOEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2865 NW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3516
Mailing Address - Country:US
Mailing Address - Phone:541-243-8199
Mailing Address - Fax:541-286-4485
Practice Address - Street 1:2865 NW 29TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3516
Practice Address - Country:US
Practice Address - Phone:541-752-0083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112118Medicare ID - Type Unspecified