Provider Demographics
NPI:1972575728
Name:KOLBECK, SASHA LAUREL (MPT)
Entity Type:Individual
Prefix:MS
First Name:SASHA
Middle Name:LAUREL
Last Name:KOLBECK
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 1:1515 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:541-297-2497
Mailing Address - Fax:
Practice Address - Street 1:1515 NW 18TH AVE
Practice Address - Street 2:STE 400
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2516
Practice Address - Country:US
Practice Address - Phone:541-297-2497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930635514OtherGROUP TAX NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR299303Medicaid
OR930635514OtherGROUP TAX NUMBER
ORR117246Medicare PIN
OR299303Medicaid