Healthcare Provider Details

I. General information

NPI: 1174939524
Provider Name (Legal Business Name): JOHANKA STAVENIK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 SW MULTNOMAH BLVD
PORTLAND OR
97219-3195
US

IV. Provider business mailing address

25117 SW PARKWAY AVE SUITE D
WILSONVILLE OR
97070-9697
US

V. Phone/Fax

Practice location:
  • Phone: 503-244-1107
  • Fax:
Mailing address:
  • Phone: 971-224-2004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: