Provider Demographics
NPI:1093063695
Name:BUSHNELL, SPENCER P (DPT)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:P
Last Name:BUSHNELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 SE CESAR E. CHAVEZ
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-4215
Mailing Address - Country:US
Mailing Address - Phone:503-254-3424
Mailing Address - Fax:
Practice Address - Street 1:9828 E. BURNSIDE ST
Practice Address - Street 2:SUITE 250
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:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6905OtherDPT LICENSE