Provider Demographics
NPI:1346270741
Name:GORE, CHERYL LYNN (PT)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:GORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 N WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1864
Mailing Address - Country:US
Mailing Address - Phone:503-288-2615
Mailing Address - Fax:503-288-0339
Practice Address - Street 1:15755 SW SEQUOIA PARKWAY
Practice Address - Street 2:#101
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224
Practice Address - Country:US
Practice Address - Phone:503-639-8284
Practice Address - Fax:503-624-7216
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR137836Medicaid
OR137836Medicaid