Provider Demographics
NPI:1215376728
Name:FLOOD, LAURA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:FLOOD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:CLUBERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PR
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 1:61615 ATHLETIC CLUB DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3247
Practice Address - Country:US
Practice Address - Phone:800-219-8835
Practice Address - Fax:503-639-9699
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500660037Medicaid
ORR170604Medicare PIN