Provider Demographics
NPI:1154659209
Name:LYTTLE, THOMAS W (PT)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:LYTTLE
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 1:1960 NW 167TH PL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4803
Mailing Address - Country:US
Mailing Address - Phone:503-672-6085
Mailing Address - Fax:503-672-6081
Practice Address - Street 1:1960 NW 167TH PL
Practice Address - Street 2:SUITE 200
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4803
Practice Address - Country:US
Practice Address - Phone:503-672-6085
Practice Address - Fax:503-672-6081
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR05441OtherOREGON STATE LICENSE
ORPENDINGMedicaid
ORPENDINGMedicare PIN