Provider Demographics
NPI:1881884740
Name:PHELPS, SHANNON R (MSPT)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:R
Last Name:PHELPS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 SW GREENBURG RD
Mailing Address - Street 2:LINCOLN CENTER 3, STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5503
Mailing Address - Country:US
Mailing Address - Phone:503-570-3665
Mailing Address - Fax:
Practice Address - Street 1:650 SE OAK ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4120
Practice Address - Country:US
Practice Address - Phone:503-648-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist