Provider Demographics
NPI:1992055206
Name:ANTONISHEN, EMILY G (DPT)
Entity type:Individual
Prefix:MS
First Name:EMILY
Middle Name:G
Last Name:ANTONISHEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:EMILY
Other - Middle Name:G
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:541-754-1150
Mailing Address - Fax:
Practice Address - Street 1:2350 NW CENTURY DR STE 100
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3495
Practice Address - Country:US
Practice Address - Phone:541-754-1265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500650076Medicaid
OR500650076Medicaid