Provider Demographics
NPI:1073933412
Name:LAURELHURST PHYSICAL THERAPY CLINIC
Entity Type:Organization
Organization Name:LAURELHURST PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TREBNICK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-254-3424
Mailing Address - Street 1:9828 E BURNSIDE ST STE 250
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2365
Mailing Address - Country:US
Mailing Address - Phone:503-254-3424
Mailing Address - Fax:503-254-3635
Practice Address - Street 1:9828 E BURNSIDE ST STE 250
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2365
Practice Address - Country:US
Practice Address - Phone:503-254-3424
Practice Address - Fax:503-254-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WCQKYMedicare PIN