Provider Demographics
NPI:1184772600
Name:PEDERSEN, LYNNE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:MARIE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9828 EAST BURNSIDE
Mailing Address - Street 2:SUITE #250
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2365
Mailing Address - Country:US
Mailing Address - Phone:503-254-3424
Mailing Address - Fax:503-254-3635
Practice Address - Street 1:9828 EAST BURNSIDE
Practice Address - Street 2:SUITE #250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2365
Practice Address - Country:US
Practice Address - Phone:503-254-3424
Practice Address - Fax:503-254-3635
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4951225100000X
WAPT00007233225100000X
OR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist