Basic Information
| Provider Information | |||||||||
| NPI: | 1912988700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLEGEL | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3439 NE SANDY BLVD | ||||||||
| Address2: | PMB 375 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032848841 | ||||||||
| FaxNumber: | 5032823302 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 NW FLANDERS ST | ||||||||
| Address2: | #103 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032221524 | ||||||||
| FaxNumber: | 5032241880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 07/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | MD13388 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 269126 | 05 | OR | MEDICAID |