Basic Information
| Provider Information | |||||||||
| NPI: | 1194971515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | BHAVANA | ||||||||
| MiddleName: | RAMASAHAYAM | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11782 SW BARNES RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032145200 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Practice Location | |||||||||
| Address1: | 11782 SW BARNES RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039064323 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 5225 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 5225 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 500611946 | 05 | OR | MEDICAID | 5225 | 01 | OR | PT LICENSE | OTHER |