Provider Demographics
NPI:1548238165
Name:KOSTA, CHERYL SHERWOOD (PT)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:SHERWOOD
Last Name:KOSTA
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 1:101 S STATE ST
Mailing Address - Street 2:SUITE 200G
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3900
Mailing Address - Country:US
Mailing Address - Phone:503-636-3028
Mailing Address - Fax:503-636-1837
Practice Address - Street 1:101 S STATE ST
Practice Address - Street 2:SUITE 200G
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3900
Practice Address - Country:US
Practice Address - Phone:503-636-3028
Practice Address - Fax:503-636-1837
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20461Medicaid
OR00WFBRKCMedicare ID - Type Unspecified