Provider Demographics
NPI:1215366729
Name:MACALUSO, RICHARD (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MACALUSO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11325 NE WEIDLER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-1950
Mailing Address - Country:US
Mailing Address - Phone:503-253-1181
Mailing Address - Fax:503-253-1871
Practice Address - Street 1:11325 NE WEIDLER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-1950
Practice Address - Country:US
Practice Address - Phone:503-253-1181
Practice Address - Fax:503-253-1871
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8856225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8856OtherPHYSICAL THERAPY ASSISTANT LICENSE