Provider Demographics
NPI:1669449153
Name:TIGARD PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:TIGARD PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARSHALL BROOK
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:503-753-1537
Mailing Address - Street 1:PO BOX 3728
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062
Mailing Address - Country:US
Mailing Address - Phone:503-597-1151
Mailing Address - Fax:503-597-1150
Practice Address - Street 1:18019 SW LOWER BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224-7228
Practice Address - Country:US
Practice Address - Phone:503-753-1537
Practice Address - Fax:503-573-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2600225100000X
OR7585225200000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
119353Medicare ID - Type Unspecified