Provider Demographics
NPI:1124207535
Name:DYBDAHL, CHAD (PT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:DYBDAHL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE. 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 1:702 SW RAMSEY AVE
Practice Address - Street 2:STE. 220
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5858
Practice Address - Country:US
Practice Address - Phone:541-479-0765
Practice Address - Fax:541-479-3461
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00802462OtherRR MEDICARE
OR278901Medicaid
OR0226042OtherWASHINGTON L & I
ORP00802462OtherRR MEDICARE