Provider Demographics
NPI:1962594960
Name:WEEDALL, SUSAN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WEEDALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17120 PILKINGTON RD STE 215
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5353
Mailing Address - Country:US
Mailing Address - Phone:503-974-9078
Mailing Address - Fax:503-620-2410
Practice Address - Street 1:17120 PILKINGTON RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5353
Practice Address - Country:US
Practice Address - Phone:503-974-9078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1294225100000X
CA19751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR135319Medicare PIN