Provider Demographics
NPI:1629275961
Name:HENDERSHOT, GWEN MARIE (DPT)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:MARIE
Last Name:HENDERSHOT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:MARIE HENDERSHOT
Other - Last Name:KURILIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1650 NW NAITO PKWY STE 185
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2535
Mailing Address - Country:US
Mailing Address - Phone:503-525-7600
Mailing Address - Fax:
Practice Address - Street 1:1130 NW 22ND AVE STE 345
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2978
Practice Address - Country:US
Practice Address - Phone:503-413-7513
Practice Address - Fax:503-413-7503
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR138701Medicare PIN