MEDICARE: ERIN MICHELLE DEROSIA P.T.

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	5405	OR

General Provider Information

NPI Number	:	1942400833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN MICHELLE DEROSIA P.T.

Provider Business Mailing Address
First Line	:	11481 SW HALL BLVD
Second Line	:	STE 201
City	:	PORTLAND
State	:	OR
Zip	:	97223-8403
Country	:	US
Telephone Number	:	503-443-6156
Fax Number	:	503-639-9699

Provider Business Practice Location Address
First Line	:	2005 ELM ST
Second Line	:	STE 200
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-2518
Country	:	US
Telephone Number	:	503-357-9810
Fax Number	:	503-357-9819

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

Provider Enumeration Date	:	07/19/2007
Last Update Date	:	11/07/2007

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