Provider Demographics
NPI:1922156363
Name:SYNSVOLL, CANDIS (PT)
Entity Type:Individual
Prefix:
First Name:CANDIS
Middle Name:
Last Name:SYNSVOLL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 SE 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3908
Mailing Address - Country:US
Mailing Address - Phone:503-236-3108
Mailing Address - Fax:503-236-3239
Practice Address - Street 1:1423 SE 23RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3908
Practice Address - Country:US
Practice Address - Phone:503-236-3108
Practice Address - Fax:503-236-3239
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116247Medicare ID - Type UnspecifiedMEDICARE NUMBER