Provider Demographics
NPI:1154013621
Name:CHANG, SHEROLYN (PTA)
Entity type:Individual
Prefix:
First Name:SHEROLYN
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12391 SW MILLVIEW CT
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-3514
Mailing Address - Country:US
Mailing Address - Phone:808-728-5481
Mailing Address - Fax:
Practice Address - Street 1:12391 SW MILLVIEW CT
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-3514
Practice Address - Country:US
Practice Address - Phone:808-728-5481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8764225200000X
WACP017930A225200000X
NVA-1071225200000X
COCP014925A225200000X
OR9848225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant