Healthcare Provider Details

I. General information

NPI: 1922527837
Provider Name (Legal Business Name): ANGELA GRACIA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 NW MILLER AVE
GRESHAM OR
97030-7260
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD STE 300
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-7644
  • Fax: 503-674-9980
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number62331
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: