Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | 4108 | OR |
Y | 2251X0800X | Physical Therapist - Orthopedic | 04108 | OR |
NPI | 1184962128 |
---|---|
Provider Name | Michele Shivack |
First Address | Portland, OR 97225-5914 |
Second Address | Portland, OR 97225-5914 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2013 |
Last Update Date | 13/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04108 | LICENSE NUMBER (01) | OR |