Provider Demographics
NPI:1962638049
Name:HIETSCHOLD, SHANNON (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HIETSCHOLD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:PIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:16180 SE SUNNYSIDE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6302
Mailing Address - Country:US
Mailing Address - Phone:503-582-4600
Mailing Address - Fax:503-582-4650
Practice Address - Street 1:16180 SE SUNNYSIDE RD STE 204
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-582-4600
Practice Address - Fax:503-582-4650
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR612272251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic