Healthcare Provider Details

I. General information

NPI: 1952386039
Provider Name (Legal Business Name): SCOTT M GULSTINE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 SW MORRISON ST SUITE 100
PORTLAND OR
97205-1916
US

IV. Provider business mailing address

1630 SW MORRISON ST SUITE 100
PORTLAND OR
97205-1916
US

V. Phone/Fax

Practice location:
  • Phone: 503-227-7774
  • Fax: 503-227-7548
Mailing address:
  • Phone: 503-227-7774
  • Fax: 503-277-7548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number3493
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: