Provider Demographics
NPI:1396220745
Name:DAVES, ALLYCIA CATHRYN (PT)
Entity Type:Individual
Prefix:MRS
First Name:ALLYCIA
Middle Name:CATHRYN
Last Name:DAVES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:ALLYCIA
Other - Middle Name:CATHRYN
Other - Last Name:SHACKELFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:113 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3519
Mailing Address - Country:US
Mailing Address - Phone:503-263-8903
Mailing Address - Fax:503-266-8632
Practice Address - Street 1:610 HIGH ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2241
Practice Address - Country:US
Practice Address - Phone:503-657-8903
Practice Address - Fax:503-266-8632
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60895521225100000X
CO0014101225100000X
OR63647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR63647OtherPT LICENSE