Provider Demographics
NPI:1356712269
Name:HALVORSEN, SHERICE
Entity type:Individual
Prefix:
First Name:SHERICE
Middle Name:
Last Name:HALVORSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97121-9716
Mailing Address - Country:US
Mailing Address - Phone:253-973-2266
Mailing Address - Fax:
Practice Address - Street 1:472 7TH AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:OR
Practice Address - Zip Code:97121-9716
Practice Address - Country:US
Practice Address - Phone:253-973-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-18
Last Update Date:2015-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60047620225200000X
OR07035225200000X
IDPTA-4262225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant