Provider Demographics
NPI:1376888107
Name:OUELLETTE, BAILEY ANN (PT)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:ANN
Last Name:OUELLETTE
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 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:13470 SW FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2618
Practice Address - Country:US
Practice Address - Phone:503-644-3311
Practice Address - Fax:503-627-0112
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500652655Medicaid
ORP01527068OtherRR MEDICARE
ORR168492Medicare PIN
OR500652655Medicaid