Provider Demographics
NPI:1326133125
Name:BLACK-ROFINOT, CORRIE ALENA (DPT)
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:ALENA
Last Name:BLACK-ROFINOT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CORRIE
Other - Middle Name:ALENA
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:11782 SW BARNES RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5933
Mailing Address - Country:US
Mailing Address - Phone:503-906-4323
Mailing Address - Fax:503-906-4333
Practice Address - Street 1:11782 SW BARNES RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5931
Practice Address - Country:US
Practice Address - Phone:503-906-4323
Practice Address - Fax:503-906-4333
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR48292251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4829OtherLICENSE NUMBER
ORR160578Medicare PIN