Provider Demographics
NPI:1104884055
Name:SEBULSKY, JOSEPH MARK (OT)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MARK
Last Name:SEBULSKY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BV
Mailing Address - Street 2:STE 201 THERAPEUTIC ASSOCIATES INC
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:1315 NW 4TH ST
Practice Address - Street 2:STE B
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1328
Practice Address - Country:US
Practice Address - Phone:541-923-7494
Practice Address - Fax:541-504-9153
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1016749225X00000X
NH1093225X00000X
VT0720000310225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231021Medicaid
OR231021Medicaid