MEDICARE: CELINE MARTHA MCCARTHY PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1471	OR

General Provider Information

NPI Number	:	1417171414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CELINE MARTHA MCCARTHY PT

Provider Business Mailing Address
First Line	:	3331 PACIFIC AVE
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1914
Country	:	US
Telephone Number	:	503-357-9374
Fax Number	:	503-359-7531

Provider Business Practice Location Address
First Line	:	3331 PACIFIC AVE
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1914
Country	:	US
Telephone Number	:	503-357-9374
Fax Number	:	503-359-7531

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	12/03/2007

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