Provider Demographics
NPI:1346558343
Name:SHELTON, SUSAN KAY (PTA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KAY
Last Name:SHELTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17510 HILL WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5414
Mailing Address - Country:US
Mailing Address - Phone:503-686-9592
Mailing Address - Fax:
Practice Address - Street 1:17510 HILL WAY
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5414
Practice Address - Country:US
Practice Address - Phone:503-686-9592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001014225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant