Provider Demographics
NPI:1659429082
Name:BORN, STEFANIE J (ATC)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:J
Last Name:BORN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 SE MOUNT HOOD HWY
Mailing Address - Street 2:#J271
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-7131
Mailing Address - Country:US
Mailing Address - Phone:503-666-6549
Mailing Address - Fax:
Practice Address - Street 1:24076 SE STARK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3373
Practice Address - Country:US
Practice Address - Phone:503-491-1666
Practice Address - Fax:503-491-1667
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-10015052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer