Provider Demographics
NPI:1528407434
Name:FORT, ROBERTA ANN (PT)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ANN
Last Name:FORT
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 1:8881 NW PIKE RD
Mailing Address - Street 2:
Mailing Address - City:YAMHILL
Mailing Address - State:OR
Mailing Address - Zip Code:97148-8208
Mailing Address - Country:US
Mailing Address - Phone:503-662-3291
Mailing Address - Fax:
Practice Address - Street 1:8881 NW PIKE RD
Practice Address - Street 2:
Practice Address - City:YAMHILL
Practice Address - State:OR
Practice Address - Zip Code:97148-8208
Practice Address - Country:US
Practice Address - Phone:503-662-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR003352251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics