Provider Demographics
NPI:1912996968
Name:ANDERSON, JOHN-HENRY (DPT, CSCS)
Entity type:Individual
Prefix:
First Name:JOHN-HENRY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPT, CSCS
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 BLVD
Mailing Address - Street 2:SUITE 201
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:503-639-9699
Practice Address - Street 1:20055 SW PACIFIC HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9294
Practice Address - Country:US
Practice Address - Phone:503-625-1691
Practice Address - Fax:503-925-1460
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT18762251S0007X
WAPT60210474225100000X
OR6672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500639222Medicaid
OR500639222Medicaid