Provider Demographics
NPI:1417016460
Name:TY, ANNABELLE (PT)
Entity Type:Individual
Prefix:
First Name:ANNABELLE
Middle Name:
Last Name:TY
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 1:21726 SW SUSAN LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-6588
Mailing Address - Country:US
Mailing Address - Phone:916-220-0846
Mailing Address - Fax:
Practice Address - Street 1:1778 NE CORNELL RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-2740
Practice Address - Country:US
Practice Address - Phone:503-648-6621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 30315225100000X
OR5589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist