Provider Demographics
NPI:1528805702
Name:RANDALL, EMILY ANNE (OTR/L)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANNE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8040 N WASHBURNE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7252
Mailing Address - Country:US
Mailing Address - Phone:415-301-1432
Mailing Address - Fax:
Practice Address - Street 1:4475 SW SCHOLLS FERRY RD STE 258
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-1958
Practice Address - Country:US
Practice Address - Phone:503-292-5882
Practice Address - Fax:503-292-5889
Is Sole Proprietor?:No
Enumeration Date:2024-07-13
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR509003225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist