Provider Demographics
NPI:1821050956
Name:SHEELY, SUSAN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:SHEELY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:2040 NW NEWCASTLE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1657
Practice Address - Country:US
Practice Address - Phone:541-673-1808
Practice Address - Fax:541-673-2117
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269708Medicaid
OR297215Medicaid
ORR194433OtherMEDICARE
OR838414000OtherBCBS
OR297215OtherOMAP
OR838414000OtherBCBS
ORR156229Medicare PIN
ORR194433OtherMEDICARE