Basic Information
| Provider Information | |||||||||
| NPI: | 1063582468 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 731269 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983730060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538402313 | ||||||||
| FaxNumber: | 2538406340 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 DENNIS ST SW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TUMWATER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985016523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607043300 | ||||||||
| FaxNumber: | 3607047676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PT00009747 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 198446 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER | 8420OB | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8429318 | 05 | WA | MEDICAID | 7600331 | 01 | WA | AETNA | OTHER | 8906262 | 01 | WA | CRIME VICTIMS | OTHER |