Provider Demographics
NPI:1447236021
Name:WHITESIDE, ALLISON (PT)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:WHITESIDE
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 1:9380 NE WORDEN HILL RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OR
Mailing Address - Zip Code:97115-9146
Mailing Address - Country:US
Mailing Address - Phone:503-538-9821
Mailing Address - Fax:
Practice Address - Street 1:403 SW DENNIS AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-3928
Practice Address - Country:US
Practice Address - Phone:503-640-3803
Practice Address - Fax:503-640-3805
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4588174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276348Medicaid
OR8383510000OtherBLUE CROSS BLUE SHIELD