Provider Demographics
NPI:1508996117
Name:CANTWELL, MICHAEL JOHN (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:CANTWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 SE 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4193
Mailing Address - Country:US
Mailing Address - Phone:503-939-9144
Mailing Address - Fax:503-254-2814
Practice Address - Street 1:12672 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-254-2652
Practice Address - Fax:503-254-2814
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR44142251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic