Basic Information
| Provider Information | |||||||||
| NPI: | 1528551892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINSWORTH | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2020 8TH AVE STE D | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970684657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033875449 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2020 8TH AVE STE D | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970684657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033875449 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 09/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT026865 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 63357 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT026865 | 01 | PA | PA PHYSICAL THERAPY LICENSE | OTHER | 63357 | 01 | OR | OR PHYSICAL THERAPY LICENSE | OTHER |