Provider Demographics
NPI:1780881656
Name:GABRIELSON, FAITH DANETTE (LPTA)
Entity type:Individual
Prefix:
First Name:FAITH
Middle Name:DANETTE
Last Name:GABRIELSON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 NW ANGELINE AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5326
Mailing Address - Country:US
Mailing Address - Phone:360-616-0924
Mailing Address - Fax:
Practice Address - Street 1:11325 NE WEIDLER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-1950
Practice Address - Country:US
Practice Address - Phone:503-251-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7364225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111589Medicaid
WA4111589Medicaid
WA505240Medicare ID - Type Unspecified