Provider Demographics
NPI:1518092964
Name:VONFOERSTER, MARILYN MILLER (PT, MA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:MILLER
Last Name:VONFOERSTER
Suffix:
Gender:F
Credentials:PT, MA
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:IDA
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, PT
Mailing Address - Street 1:577 BONNIE CT NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3208
Mailing Address - Country:US
Mailing Address - Phone:503-365-7554
Mailing Address - Fax:503-364-4872
Practice Address - Street 1:577 BONNIE CT NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3208
Practice Address - Country:US
Practice Address - Phone:503-365-7554
Practice Address - Fax:503-364-4872
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2190225100000X
CA5435225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR030172000OtherREGENCE BLUECROSS BLUESHI
OR182439Medicaid
OR3203119-01OtherFC65, MEDICARE ADVANTAGE
ORR133956Medicare ID - Type UnspecifiedPHYSICAL THERAPY