1467425108 NPI number — MRS. CATHERINE WILLIS OTR L

Table of content: MRS. CATHERINE WILLIS OTR L (NPI 1467425108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467425108 NPI number — MRS. CATHERINE WILLIS OTR L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
CATHERINE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNOCHE
Provider Other First Name:
CATHERINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1467425108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24988
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-0988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-639-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 NW 4TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
REDMOND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97756-1328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-923-7494
Provider Business Practice Location Address Fax Number:
541-504-9153
Provider Enumeration Date:
02/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  1066077 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 339238 . This is a "PROVIDENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: H254810 . This is a "PACIFIC SOURCE BCBS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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