Provider Demographics
NPI:1366478299
Name:DEARDORFF, LAILA (PT)
Entity Type:Individual
Prefix:
First Name:LAILA
Middle Name:
Last Name:DEARDORFF
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 1:17079 CANAL CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5613
Mailing Address - Country:US
Mailing Address - Phone:503-267-8952
Mailing Address - Fax:
Practice Address - Street 1:17079 CANAL CIR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5613
Practice Address - Country:US
Practice Address - Phone:503-267-8952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117712Medicare ID - Type UnspecifiedPHYSICAL THERAPIST