MEDICARE: MIRIAM KRISITIYAHNA WHITE OTD, OTR/L

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	390200000X	Student in an Organized Health Care Education/Training Program
2	225X00000X	Occupational Therapist	278883	OR

General Provider Information

NPI Number	:	1639402027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM KRISITIYAHNA WHITE OTD, OTR/L

Provider Business Mailing Address
First Line	:	PO BOX 6689
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97228-6689
Country	:	US
Telephone Number	:	503-413-3900
Fax Number	:	503-413-3710

Provider Business Practice Location Address
First Line	:	19250 SW 65TH AVE STE 125
Second Line	:
City	:	TUALATIN
State	:	OR
Zip	:	97062-7745
Country	:	US
Telephone Number	:	503-692-1670
Fax Number	:	503-692-1669

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

Provider Enumeration Date	:	09/16/2009
Last Update Date	:	03/10/2015

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Directions to “ MIRIAM KRISITIYAHNA WHITE OTD, OTR/L” Practice Location

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