Provider Demographics
NPI:1295784122
Name:WEISS, ANNA REBECCA (DPT)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:REBECCA
Last Name:WEISS
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 1:1040 NW 22ND AVE
Mailing Address - Street 2:SUITE LL015
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3057
Mailing Address - Country:US
Mailing Address - Phone:503-413-7009
Mailing Address - Fax:503-413-7109
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:SUITE LL015
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-413-7009
Practice Address - Fax:503-413-7109
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019887Medicaid
OK130803Medicare ID - Type Unspecified
OR019887Medicaid