Provider Demographics
NPI:1952926529
Name:WAKER, ELLIE (PT)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:WAKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:HOCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:503-443-6156
Mailing Address - Fax:
Practice Address - Street 1:2925 RIVER RD S STE 200
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3677
Practice Address - Country:US
Practice Address - Phone:503-585-4824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist