Provider Demographics
NPI:1689411241
Name:LEITH, KATRINA (CHW)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:LEITH
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-5124
Mailing Address - Country:US
Mailing Address - Phone:541-426-7958
Mailing Address - Fax:541-426-2660
Practice Address - Street 1:601 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-5124
Practice Address - Country:US
Practice Address - Phone:541-426-7958
Practice Address - Fax:541-426-2660
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000111656171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator