Provider Demographics
NPI:1538223706
Name:ROSE, RENSKE ELVIRA (MPT)
Entity type:Individual
Prefix:
First Name:RENSKE
Middle Name:ELVIRA
Last Name:ROSE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:RENSKE
Other - Middle Name:ELVIRA
Other - Last Name:WIERSTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:685 36TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4741
Mailing Address - Country:US
Mailing Address - Phone:503-540-8701
Mailing Address - Fax:503-371-8772
Practice Address - Street 1:2521 BOONE RD SE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9391
Practice Address - Country:US
Practice Address - Phone:503-585-5131
Practice Address - Fax:503-585-4065
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist