Provider Demographics
NPI:1497104145
Name:DUTTON, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:DUTTON
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 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:413 NW LARCH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1396
Practice Address - Country:US
Practice Address - Phone:541-923-7494
Practice Address - Fax:541-504-9153
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500709711Medicaid
ORR188282Medicare PIN