Provider Demographics
NPI:1689152597
Name:ANDERSON, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:DOMERMUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1515 NW 18TH AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2516
Mailing Address - Country:US
Mailing Address - Phone:423-682-8840
Mailing Address - Fax:423-602-2028
Practice Address - Street 1:300 GLEN CREEK RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304
Practice Address - Country:US
Practice Address - Phone:503-990-8627
Practice Address - Fax:503-990-8630
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62903225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist