Basic Information
| Provider Information | |||||||||
| NPI: | 1841448495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINTZ | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JONES | ||||||||
| OtherFirstName: | KATRINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | COTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1174 MADDY AVE NE | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973034118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033900661 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5210 RIVER RD N | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973034568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033933624 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 04/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 247693 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.