Basic Information
| Provider Information | |||||||||
| NPI: | 1144885294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENDERDINE | ||||||||
| FirstName: | BROOKS | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6050 TACOMA MALL BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984096828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535815200 | ||||||||
| FaxNumber: | 2535815203 | ||||||||
| Practice Location | |||||||||
| Address1: | 16222 MERIDIAN E STE 101 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983756332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538647595 | ||||||||
| FaxNumber: | 2538640457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/10/2021 | ||||||||
| NPIReactivationDate: | 10/14/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60944647 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.