Provider Demographics
NPI:1639186141
Name:SMITH, ALLISYN NICOLE (MPT, DPT)
Entity Type:Individual
Prefix:
First Name:ALLISYN
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10180 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12250 SW GARDEN PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8246
Practice Address - Country:US
Practice Address - Phone:503-684-7246
Practice Address - Fax:503-624-0724
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4391225100000X
CAPT26468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist