Basic Information
| Provider Information | |||||||||
| NPI: | 1184962128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIVACK | ||||||||
| FirstName: | MICHELE | ||||||||
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| Credential: | PT,ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039064323 | ||||||||
| FaxNumber: | 5039064333 | ||||||||
| Practice Location | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039064323 | ||||||||
| FaxNumber: | 5039064333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2013 | ||||||||
| LastUpdateDate: | 09/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | 4108 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | 04108 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 04108 | 01 | OR | LICENSE NUMBER | OTHER |