=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881040731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEBORAH THRALL PT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2016
-----------------------------------------------------
Last Update Date | 05/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2077 NW TOWN CENTER DR
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-8938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-324-7842
-----------------------------------------------------
Fax | 503-207-6185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24020 NW RIDGE RD
-----------------------------------------------------
City | FOREST GROVE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97116-9266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-324-7842
-----------------------------------------------------
Fax | 503-207-6185
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | DEBORAH CARPENTER THRALL
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 503-324-7842
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------