MEDICARE: JOANNE GORHAM PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	7314	OR

General Provider Information

NPI Number	:	1336342443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANNE GORHAM PT

Provider Business Mailing Address
First Line	:	6821 N NEWCASTLE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-5348
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 NW 22ND AVE
Second Line	:	SUITE 200
City	:	PORTLAND
State	:	OR
Zip	:	97210-2900
Country	:	US
Telephone Number	:	503-413-8988
Fax Number	:	503-274-4815

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	07/08/2007

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