Provider Demographics
NPI:1760031496
Name:NEGRILA, CARLY LYNN (PT)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:LYNN
Last Name:NEGRILA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:LYNN
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:503-443-6156
Mailing Address - Fax:
Practice Address - Street 1:2005 ELM ST STE 200
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2781
Practice Address - Country:US
Practice Address - Phone:503-357-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist