=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700138856
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN Z. GRBAVAC O'HALLORAN PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2012
-----------------------------------------------------
Last Update Date | 03/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 PORTLAND ROAD SUITE 102
-----------------------------------------------------
City | NEWBERG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-537-1462
-----------------------------------------------------
Fax | 503-537-1808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 PORTLAND ROAD SUITE 102
-----------------------------------------------------
City | NEWBERG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-537-1462
-----------------------------------------------------
Fax | 503-537-1808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT009008
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT04909
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------