Provider Demographics
NPI:1780795120
Name:STEWART, SUE ELLEN (PT)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:STEWART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:ELLEN
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:12540 SW 68TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8597
Mailing Address - Country:US
Mailing Address - Phone:503-974-9078
Mailing Address - Fax:503-974-9083
Practice Address - Street 1:12540 SW 68TH AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8597
Practice Address - Country:US
Practice Address - Phone:503-974-9078
Practice Address - Fax:503-974-9083
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist