Provider Demographics
NPI:1801879614
Name:DAILEY, SHAWN VINDEL (PT)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:VINDEL
Last Name:DAILEY
Suffix:
Gender:M
Credentials:PT
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:STE 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 1:4829 NE MARTIN LUTHER KING BLVD
Practice Address - Street 2:STE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3351
Practice Address - Country:US
Practice Address - Phone:503-283-8133
Practice Address - Fax:503-289-2312
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213465Medicaid
OR213465Medicaid