Provider Demographics
NPI:1932181062
Name:MCCORMICK, SHANDA AILENE (PT)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:AILENE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:13470 SW FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2618
Practice Address - Country:US
Practice Address - Phone:503-644-3311
Practice Address - Fax:503-627-0112
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR299951Medicaid
OR117097Medicare PIN