Provider Demographics
NPI:1346002250
Name:LABTHAVIKUL, SY (PTA)
Entity Type:Individual
Prefix:MR
First Name:SY
Middle Name:
Last Name:LABTHAVIKUL
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 1:412 SE 30TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1921
Mailing Address - Country:US
Mailing Address - Phone:845-598-7495
Mailing Address - Fax:
Practice Address - Street 1:10915 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3348
Practice Address - Country:US
Practice Address - Phone:503-261-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9796225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant