Provider Demographics
NPI:1417954561
Name:TREBNICK, SUZANNE M (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:M
Last Name:TREBNICK
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 1:9828 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2354
Mailing Address - Country:US
Mailing Address - Phone:503-254-3424
Mailing Address - Fax:503-254-3635
Practice Address - Street 1:9828 E BURNSIDE ST SUITE 250
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2354
Practice Address - Country:US
Practice Address - Phone:503-254-3424
Practice Address - Fax:503-254-3635
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00WCQKYAMedicare UPIN