Basic Information
| Provider Information | |||||||||
| NPI: | 1760640213 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BLIEVERNICHT | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | D.P.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 15280 NW CENTRAL DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972297805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034662254 | ||||||||
| FaxNumber: | 5034661143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 10/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11016 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5973 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 500609437 | 05 | OR | MEDICAID | P00802449 | 01 | OR | RR MEDICARE | OTHER | 0252231 | 01 | OR | WASHINGTON L&I | OTHER |