Provider Demographics
NPI:1699102335
Name:DECASTRO, KATHLEEN MARIE (DIETETIC TECHNICIAN)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:DECASTRO
Suffix:
Gender:F
Credentials:DIETETIC TECHNICIAN
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:DECASTRO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DT
Mailing Address - Street 1:14175 SW 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-5972
Mailing Address - Country:US
Mailing Address - Phone:503-684-2969
Mailing Address - Fax:
Practice Address - Street 1:14175 SW 89TH AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-5972
Practice Address - Country:US
Practice Address - Phone:503-684-2969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist