Provider Demographics
NPI:1619259009
Name:MAXTED, DEBRA JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:MAXTED
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53335 E HWY 26
Mailing Address - Street 2:PO BOX 1213
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055
Mailing Address - Country:US
Mailing Address - Phone:503-622-5882
Mailing Address - Fax:
Practice Address - Street 1:420 SE MYRA ROAD
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324
Practice Address - Country:US
Practice Address - Phone:509-529-4480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160234599225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant