Provider Demographics
NPI:1114362944
Name:BRYSON, VICTORIA (PT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BRYSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:20055 SW PACIFIC HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9294
Practice Address - Country:US
Practice Address - Phone:503-625-1691
Practice Address - Fax:503-925-1460
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60041225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01491759OtherRR MEDICARE PTAN
OR500657071Medicaid
OR500657071Medicaid