Provider Demographics
NPI:1548241995
Name:PROVENZANO, C THOMAS (MPT)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:THOMAS
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 NE HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5343
Mailing Address - Country:US
Mailing Address - Phone:503-280-7346
Mailing Address - Fax:503-255-1560
Practice Address - Street 1:9260 SE STARK ST
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-1675
Practice Address - Country:US
Practice Address - Phone:503-255-1500
Practice Address - Fax:503-255-1560
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist