Provider Demographics
NPI:1710126198
Name:GUILFOYLE, SHAWNA AVRIL (OT)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:AVRIL
Last Name:GUILFOYLE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 SE LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6150
Mailing Address - Country:US
Mailing Address - Phone:323-568-6571
Mailing Address - Fax:
Practice Address - Street 1:1729 SE LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6150
Practice Address - Country:US
Practice Address - Phone:323-568-6571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2432225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2432OtherOCCUPATIONAL THERAPY LICENSE
OR278527Medicaid