Provider Demographics
NPI:1801906540
Name:BROWN, AMY (LMT, PTA, CSCS)
Entity type:Individual
Prefix:MISS
First Name:AMY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:LMT, PTA, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 NW NAITO PKWY
Mailing Address - Street 2:M16
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3768
Mailing Address - Country:US
Mailing Address - Phone:503-980-5712
Mailing Address - Fax:
Practice Address - Street 1:625 NW 17TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2209
Practice Address - Country:US
Practice Address - Phone:503-980-5712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
OR19726174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8072OtherLICENSE #
OR19726OtherLMT
OR8072OtherPHYSICAL THERAPISTS ASSISTANT
7247825326OtherCERTIFIED STRENGTH & CONDITIONING SPECIALIST