Provider Demographics
NPI:1053383430
Name:OUELLETTE, AMY LEIGH (DPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LEIGH
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LEIGH
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:21178 SW LADYFERN DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8955
Mailing Address - Country:US
Mailing Address - Phone:541-399-6961
Mailing Address - Fax:503-405-7448
Practice Address - Street 1:21178 SW LADYFERN DR
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8955
Practice Address - Country:US
Practice Address - Phone:541-399-6961
Practice Address - Fax:503-405-7448
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5105225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005727Medicaid